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THEORETICAL AND PRACTICAL 



TREATISE 



ON 



HUMAN PARTURITION. 



BY H. MILLER, M. D. 



PROFESSOR OF OBSTETRICS AND THE DISEASES OF WOMEN AND 

CHILDREN, IN THE MEDICAL DEPARTMENT OF 

THE UNIVERSITY OF LOUISVILLE. 



LOUISVILLE : 
JOHN Y. COWLINa & GEO. C. DxiVIES. 

CINCINNATI : H. W. DERBY & CO. 
NEW YORK : A. S. BARNES & CO. 

1849. 






Entered according to act of Congress, in the year of our Lord, 
1849, by Henry Miller, in the Clerk's Office of the District 
Court, for the District of Kentucky. 



DEDICATION 



To the Pupils who have attended his Lectures on 
Obstetrics, etc., this Treatise, — a faithful remembran- 
cer of the principles and practice which he sedulously 
endeavored to instill into them, — is respectftilly and 

cordially inscribed, by 

THE AUTHOR. 



PREzFACE. 



A MAN, in becoming an author, may be permitted to hold a 
free and easy colloquy with his reader, without justly exposing 
himself to the charge of egotism, even should he speak of himself, 
his plans, hopes, and expectations, more than is seemly in ether 
situations. No one writes without presuming that he is able to 
teach ; and the success of his undertaking depends very much, on 
establishing at the outset, a degree of familiarity between himself 
and his reader, on the same principle that a schoolmaster relaxes 
his magisterial brow, and playfully receives the little urchins at 
their first meeting, not forgetting to pat their little chubby cheeks, 
and tell them something about himself Taking it for granted 
that this privilege will be conceded, you are to know, indulgent 
reader, that the author of the work you are now peeping into is a 
man rather advanced in life ( though yoii need not be precisely in- 
formed of his age — that is a delicate point — ), who has seen 
much and read some, touching the subjects he proposes to handle ; 
and has withal been accounted qualified to teach others what it has 
been his chief pleasure to practice, since he was a very young 
man. He loves his vocation, notwithstanding the difficult and re- 
sponsible duties it imposes, and would not exchange it for any 
other ; to this attachment, more than to superior capacity, he hon- 
estly ascribes whatever proficiency or eminence he may have at- 
tained in it. Eeader, if you have not this love, you have mistaken 
your calling. For the rest, the author is a backwoodsman, having 
been brought to light in Kentucky, by a process which it is his 
purpose to unfold in this treatise. His education was not acquired 
in academic halls, but in the primitive schoolhouses of his native 
state, and upon the ample sward, shaded by forest trees, appurtenant 
thereunto : so that, you see, he was reared after the fashion of Soc- 



vi PREFACE. 



rates, imbibing knowledge in tbe seboolhonse, under the shade of 
trees, and not unfrequently perched upon their boughs. 

But the author prates, you say ; he had better tell us why he 
has taken it into his head to write a book on midwifery, for we 
do n't see the use of it: we have books enough already; — there 
arc Baudelocque's ( an abridged translation of it ), Denman's, 
Burns's, Bewees's, and more recently, translations of Yelpeau,Chailly 
and Morcau, to say nothing of Gooch, Hamilton, Blundell, Bigby, 
Churchill, Collins, Bamsbotham, Lee, Murphy, Maunsell, etc., etc., 
whose works have been published on this side of the Atlantic ; and 
has not Dr. ^leigs published a book, the " Philadelphia Practice 
of Midwifery ? " 

Truly, reader, we have books enough and to spare, as far as 
numbers are concerned. Far be it from the author to disparage 
any of the works that have been named ; they all have their ex- 
cellencies, and, like every human production, their faults; but their 
multitude cries aloud for another. While they have disseminated 
knowledge and enlightened the highways and byways of practice, 
and thus been instrumental in achieving much good, they have un- 
settled the minds of practitioners in regard to points of deepest 
interest, and made a wreck of obstetrical nom.enclaturc, as far as 
the presentations and positions of the fetus are concerned. 

To justify the first assertion, namely, that doubts and perplexi- 
ties have been engendered, in relation to matters of fact, which it 
behooves us to understand clearly, the author will refer only to the 
discrepant statements to be found among these writers, regarding 
the manner in which the child is transmitted through the pelvis, in 
the different presentations and positions. . Surely, no man is fit to 
practice midwifery, or, at least, no man can practice it with facility 
to himself and in the safest manner for his patient, who does not 
understand what he may have occasion to imitate, in artificial de- 
liveries. The mechanism of labor, as the child's passage through 
the pelvis, in obedience to certain mechanical requisitions, has 
been called, ought, therefore, to be settled. It may be learnt, and 
can only be learnt, by observation. How, then, has it happened 
that we liave such contradictory accounts of matters of fact ? To 
give a full, correct, and lucid description of the mechanism of labor 
is a leading object which the author had in view, in writing his 



PREFACE. vii 



book. In the prosecution of it, he has not hesitated to examine 
rigorously and criticise freely the statemsnts and opinions of others ; 
and trusts that he has succeeded in tracing the true track of thk^ 
fetus, in its advent, amid the devious windings of the paths that 
have been marked out in obstetric charts. 

The fetal presentations and positions have been thrown into a 
hotchpotch, which is the second assertion to be proved ; and ob- 
stetricians can no more communicate with each other concerning 
them, in technology generally understood, than could the Babel- 
builders after the confusion of tongues. The time was, when the 
classification and nomenclature of Baudelocque, under the auspices 
of Dr. Dewees, universally prevailed in this country ; and although 
his system was not free from serious objections, it was better with 
us then than now, for the language of obstetrical science was 
everywhere understood. In most countries there is, and in all 
there ought to be, some standard agreed upon relative to this part 
of obstetrical medicine ; but how can such agreement exist, in a 
country like ours, which tamely consents to receive its science as 
weU as its fashions from abroad. We need, at this time, a native 
authority to educe order out of confusion, and set up a national 
standard, under which all our practitioners may arrange them- 
selves, and be cemented by a common bond of union. 

To review the whole subject of presentations and positions, 
with the light which his own experience and that of others has 
shed upon it, since the time of Baudelocque, and establish for them 
a classification and nomenclature which, it seems to him, all may 
adopt, is another object which the author has in view in ofi'ering 
this volume to the profession. The classification which he recom- 
mends is that of M. Duges, but the nomenclature is his own. In 
venturing to hope that he may be instrumental in giving stabiHty 
to this fundamental part of obstetrics, at least in his own country, 
the author knows full well that he may incur the imputation of 
presumptuousness. What! it will be said, does a backwoodsman 
presume to erect a standard, and expect all who are engaged in 
teaching or practicing midwifery, in this great confederacy, to rally 
around it? Whatever may be the fate of his enterprise, he con- 
fesses that this aim, in this particular, is directed to no lower 
mark. Long ago, it was said or sung, " Westward the star of em- 



viii PREFACE. 



pire takes its way," and Avliy may it not have readied the hanks 
of the Ohio by this time ? 

The author will only detain the reader long enough to disclose 
the drift of his work, in the preceptive and practical parts of it. 
This may be expressed in few words, by the avowal that his prin- 
ciples of practice are essentially the same as those of Hamilton 
and Burns, — two eminent Scottish teachers and practitioners of 
midwifery. For the information of such as are not so familiar 
with the writings of these northern lights as they ought to be, it 
may be stated that they regard labor as an exhausting struggle, 
which, when unusually protracted or difficult, needs the fostering 
care and the judicious assistance of the accoucheur, although 
there may be no present indications of danger, lest harm re- 
sult from its prolongation. This manner of viewing labor ne- 
cessarily leads to a closer inquisition into it, at the bedside, and 
greater attention to the removal of whatever may embarrass 
ifc, than is agreeable to the expectant practice so much lauded 
by most, if not all, other writers. Whoever adopts it may, 
therefore, reckon upon being branded with such epithets as " offi- 
cious," "pragmatic," "meddlesome," etc.; but he will have the 
satisfaction to know that his is a ministry of help, at a time when 
the weakness of human nature most loudly calls for it, and not of 
idle contemplation. 

Louisville, January 8, 1849. 



CONTENTS 



CHAPTER I. 

The obstetric properties of tlie pelvis, _ - - 1 

CHAPTER II. 
Obstetric aptitudes of tbe fetus, 18 

CHAPTER III. 

Of tbe appurtenances of the fetus, . - - - 35 

Tbe fetal membranes, - - - - - - B5 

The placenta, ------- 36 

The umbilical cord, 50 

CHAPTER IV. 

The uterus considered as an organ destined to expel the 

fetus, - - --- - - - 55 

CHAPTER V. 

Labor — its efficient cause, ----- 80 

Of the muscular contractions of the uterus, - - 83 

CHAPTER YI. 

Of the determinative cause of labor, - - - - . 95 

CHAPTER VII. 

Phenomena of the first stage of labor, - - - 112 

Pains, 112 

"Show" — "glairs," 115 

Dilatation of the os uteri, ----- 115 

Formation of membraneous pouch, - - - 116 



CONTENTS. 



CHAPTER VIII. 

The treatment of tlie first stage of labor, - - . 127 

Obliquity of the uterus, _ . . _ 136 

Inefficient action of the uterus, - - _ . 143 

CHAPTER IX. 

Treatment of the first stage, concluded, - - - 154 

Impeded action of the uterus, - - - 154 

Morbidly resisted action of uterus, - - - 158 

CHAPTER X. 

Common phenomena of second stage of labor, - - 168 

Rupture of the membranes, - _ _ _ 168 

Ejectment of the fetus, - - - - - 170 

Changes of the uterine circulation, - - 173 

CHAPTER XI. 

Common treatment of second stage of labor, - - 180 

Inefficient action of the uterus, - - - 186 

CHAPTER XII. 

Impotent action of the uterus, - - - - 200 

CHAPTER XIII. 

Presentations and positions of the fetus, - - 215 

Presentations of the vertex, - - - - 224 

Presentations of the pelvic extremity of the fetus, 229 

Presentations of the face, - - - - 233 

Presentations of the right and left shoulders, - - 234 

CHAPTER XIV. 
The mechanism, diagnosis, and prognosis of vertex presen- 

sentations, ------- 237 

Mechanism, 237 

Diagnosis, 272 

Prognosis, 276 



CONTENTS. xi 



CHAPTEE XV. 

Manual assistance when the liead or shoulders are passing, 
— or when, the head being born, the cord is coiled 
round the neck — the expulsion of the head retarded 
by its occipito -posterior position, or by contraction 
of the cervico -uterine orifice about the neck of the 
chHd, - - 277 

CHAPTER XVI. 

Instrumental delivery in vertex presentation, - - 290 

Delivery by the forceps, - . - - _ 290 

" crotchet, 305 

CHAPTER XVII. 

Nates presentations, .313 

Mechanism, - - - - - - -314 

Diagnosis, 325 

Prognosis, - - - -.- - - - 336 

CHAPTER XVIII. 
Treatment of nates presentation, ----- 340 

CHAPTER XIX. 

Face presentation, 352 

Mechanism, 354 

Diagnosis, 360 

Prognosis, ------- 3^2 

CHAPTER XX. 
Treatment of face presentation, . - - _ 3^9 

CHAPTER XXI. 

Shoulder presentations, 381 

Mechanism, - - 381 

Diagnosis, 386 

Prognosis, 389 



xii CONTENTS. 



CHAPTER XXII. 

Treatment of slioulder presentations, - - - _ 393 

CHAPTER XXIII. 

Phenomena and management of the third stage of labor, - 408 

CHAPTER XXIV. 

Treatment of the third stage of labor, - - - - 423 

Asphyxia neonatorum, ----- 423 

Morbid retention of the placenta, _ - - 430 

Uterine hemorrhage, 445 



A THEORETICAL AND PRACTICAL 

TKEATISE ON 

HUMAN PARTURITION 



CHAPTER I. 

THE OBSTETRIC PROPERTIES OF THE PELVIS. 

Parturition^ consisting in the expulsion of the fetus 
at maturity, is an active process, and implies, 1. The 
agency of an expulsive organ; 2. A fetus to be expel- 
led; 3. The transition of this fetus through an appro- 
priate passage. AH these are, in fact, concerned in the 
process. The uterus is the organ destined to expel the 
fetus, and the pelvis furnishes the passage through 
which it is transmitted. An acquaintance with these 
objects possesses us with the rudiments of obstetrics; 
and as well might we, ignorant of the points of the 
compass, undertake to study the course of streams, as, 
unacquainted with the uterus, fetus, and pelvis, attempt 
to investigate the phenomena of childbirth. We shall, 
therefore, begin with these rudiments, taking them up, 
however, in an adverse order to that in which they have 
been enumerated. 
1 



RUDIMENTS OF PARTURITION. 



And, first, of the pelvis. It is not without rea- 
son, that the French writers so frequently compare the 
passage of the fetus through the pelvis to the process 
of wire-drawing, in their common allusion to the pelvic 
canal, as une espcce de fiUere. The size of the fetus 
corresponds, in fact, so nicely to the capacity of the 
canal, that it can only be transmitted by having its 
more voluminous parts presented in the most advanta- 
geous manner; and should it offer otherwise, its volume 
must be reduced or its position changed, before it can 
be ushered into the world. 

The framework of the pelvis, in the adult human 
female, with whom alone we are at present concerned, 
is composed of four distinct bones, viz., the sacrum, 
coccyx, and two innominata. It is an irregular cavity, 
having the sacrum and coccyx for its posterior wall, 
and the innominata for its latteral and anterior walls. 
Each of these last bones consisted originally of three 
separate pieces, namely, the ilium, ischium, and pubis, 
whose union becomes, as growth advances, so intimate 
that the marks of their former separation are entirely 
effaced. 

It is no part of my plan to enter into an anatomical 
description of these bones, as all writers on midwifery 
have done. For such a description I refer the unin- 
formed reader to the proper authorities, viz., writers on 
anatomy, whom he must carefully study, with the bones 
before him, or else he cannot be prepared to follow me 
in the general and purely obstetric views, which I pro- 
pose to take. 

The pelvis, considered as a whole, extends from the 
highest points of the iliac cristse to the tuberosities of 



OBSTETRIC PROPERTIES OF THE PELVIS. 



the ischia. If we contemplate it in this Hght^ in the 
skeleton, it will be discovered that its lateral walls are 
much higher than its anterior or posterior wall, above 
which, especially the anterior wall, there is a great 
vacuity, between the anterior superior spinous processes 
of the ilia. The posterior of these vacuities, in the re- 
cent subject, is filled up by the lumbar vertebrae and 
muscles, etc., belonging to this region, while the anterior 
is occupied by the inferior portions of the abdominal 
muscles, with thek fasciae and integuments. 

The inferior portion of the lumbar division of the 
spine, to a level with the ihac cristse, and the interve- 
ning soft parts, together with the muscles, etc., occupy- 
ing the great vacuity in front (namely, the whole of 
what is called the hypogastric region of the abdomen) , 
may be justly reckoned as belonging to that division of 
the pelvis which is called, by obstetrical writers, the 
greater or false, to distinguish it from the lesser or true, 
pelvis. This gTcater pehds is separated from the lesser 
by a line, the ileo-pedineal, which is sharp on the supe- 
rior face of the horizontal branch of the ossa pubis or 
pectinis, and smooth and rounded on the internal face 
of the ilia. 

The greater pelvis, however important it may be du- 
ring pregnancy (affording, as it does, soft cushions lat- 
erally for the gravid uterus to rest upon, and a yielding 
wall anteriorly to allow this organ to gravitate forward), 
possesses no interest in a paturient point of view, be- 
cause it forms no part of the canal, through which the 
fetus is transmitted in childbirth. The observations I 
shall offer will, therefore, have reference exclusively to 
the true pelvis, and, this being premised, there will be 



RUDIMENTS OF PARTURITION. 



no occasion henceforth to apply any discriminating epi- 
thet to it. When the term pelvis is used, it will be 
understood to mean the true pelvis. 

The pelvis then, it may be remarked, offers for our 
study ttvo straits and an intermediate excavation^ with 
which we must be familiarly acquainted, in order that 
we may have any just conceptions of its obstetric pro- 
perties. Let us consider these separately. 

First. The superior strait, called also the aldominal 
strait, Irim of the pelvis, etc., is the entrance to the 
pelvic excavation ; and is formed by the linea ilio-pecti- 
nea anteriorly and laterally, and the superior edge of 
the promontory and wings of the sacrum posteriorly. 
Its figure is that of an irregular ellipsis, being notched 
posteriorly by the promontory of the sacrum, which has 
caused it to be compared to the heart of a playing card. 
For the purpose of estimating its dimensions, several 
diameters are ascribed to it. One of these extends 
from the symphysis pubis to the top of the sacrum, and 
is called the anteroposterior, the sacro-pubic, or conju- 
gate diameter. Another crosses this at right angles, 
bisecting it, and extending, of course, from the middle 
of the lower edge of one iliac fossa to a corresponding 
point of the other. This is the transverse or hisiliae 
diameter. A third extends from the left acetabulum to 
the right sacro-iliac symphysis, crossing the strait ob- 
liquely at the point of intersection of the former two, 
and is the left oblique diameter. The fourth and last 
stretches from the right acetabulum to the left sacro- 
iliac symphysis, being the right ohUqiie diameter. 

With regard to the designation of the oblique diame- 
ters, it is necessary to observe, that I adopt M. Gaze- 



OBSTETRIC PROPERTIES OF THE PELVIS. 



aux's, rather than Dr. Rigby's, nomenclature. Dr. 
Rigby, tracing these diameters from the sacro-ihac sym- 
physis to the acetabula, distinguishes our left as the 
right, and vice versa. In describing the mechanism of 
parturition, it will, I think, be evident that M. Cazeaux's 
method is much more natural, and will be less liable to 
perplex the student. 

The measurement of these several diameters is vari- 
ously stated by authors. Without enumerating their 
discrepancies, it will be sufficient to observe that the 
sacro-jnibic is the shortest, and measures about four 
inches ; that the transverse is the greatest, when the 
bones of the pelvis are divested of soft parts, and mea- 
sures about five inches ; Avhile the oblique diameters are 
equal to one another, and measure about four and a 
half inches. Let it be observed that the transverse 
diameter is not allowed to be the greatest, except in the 
naked pelvis. The oblique diameters are, in fact, the 
greatest in the living body, — the transverse being 
abridged by the overhanging of the muscles and blood- 
vessels, that run along the sides of the brim of the 
pelvis. 

The i^lcine of the superior strait is necessarily so often 
referred to by obstetrical authors, that it is very impor- 
tant the student should get a clear idea of it. It is 
nothing more than the area included within the boun- 
daries of the strait. If, for example, a piece of paste- 
board be cut to fit the strait, and adjusted to it, it will 
represent the plane in question. The direction of this 
plane, relatively to the axis of the body, is to be care- 
fully noticed. The spinal column may represent the 
axis of the body ; and if the pelvis be observed in con 



RUDIMENTS OF PARTURITION. 



nection with the skeleton, it will be perceived that the 
plane of the superior strait is not placed horizontally, so 
as to make a right angle with the axis of the body, but 
it dips toward the horizon, and forms an obtuse angle 
with that axis. In estimating the degree of this inclina- 
tion, it will be sufficiently accurate to say that it makes, 
with the axis of the body, nptvard and fonvard^ an 
angle of one hundred and thirty-five degrees. 

The superior strait has, also, an axis^ which is an 
imaginary straight line passing through the center of its 
plane, perpendicular to its surface. Such a line, pro- 
duced upward, passes near the umbilicus, while its other 
extremity is directed toward the last bone of the os 
coccygis. It makes, consequently, iipivard and fonvardy 
an acute angle, estimated at forty-five degrees, with the 
axis of the body. 

Secondly. The inferior strait^ called also the peri- 
neal^ is the outlet of the pelvis. In the skeleton, it is 
an exceedingly irregular aperture, having the point of 
the OS coccygis, the inferior notched edges of the ilia, 
the posterior edges and tuberosities of the ischia, and 
the rami of the ischia and pubes, for its boundaries. 
The depth of the notches, between the sacrum and in- 
nominatum, on both sides, is greatly diminished by the 
sacro-ischiatic ligaments, which convert their upper 
portion into large foramina, through which bloodvessels, 
nerves, etc., pass out of the pelvis to the inferior ex- 
tremities. In estimating the dimensions of the inferior 
strait, it is usual and proper to consider it with these 
lio-aments attached. 

That part of the inferior strait, comprised between 
the rami of the pubis and ischium of each side, and the 



OBSTETRIC PROPERTIES OF THE PELVIS. 



symphysis pubis above, and a line drawn from one ischi- 
atic tuberosity to the other, is called the arch of the 
pubis, ov the pubic arch; and is, obstetrically considered, 
the most interesting portion of the inferior strait, be- 
cause through it the fetus emerges into external life, 
and the facility of its emergence depends very materi- 
ally upon the proper construction of this arch. Suita- 
ble width is one essential requisite, and aversion of the 
edges of the flat bones that form its sides, is another, — 
in both which respects, the female differs from the male 
pelvis. 

The inferior strait has the same number of diameters 
as the superior, viz., an antero-posterior or coccy-pubic, 
a transverse or hisischiatic, and two oblique diameters. 
The antero'posterior diameter extends from the under 
part of the symphysis pubis to the point of the os coc- 
cygis, — the bisiscliiatic, from the inner part of the 
tuberosity of one ischium to the corresponding part of 
the other, — the left oblique diameter, from the junction 
of the rami of the left pubis and ischium to the middle 
of the lower edge of the right sacro-ischiatic ligament, — 
the right oblique diameter, from the junction of the 
rami of the right pubis and ischium to the middle of 
the lower edge of the left sacro-ischiatic hganient. 
With regard to the measurement of these diameters, 
the same differences are to be found among authors, as 
in reference to the superior strait. Baudelocque, and 
most of the French authors, state that they are equal 
to one another, and measure four inches; and this is 
not far from the truth in the dried pelvis, with the hga- 
ments attached ; but in the living body, both the antero- 
posterior and the oblique may be rendered more capa- 



RUDIMENTS OF PARTURITION. 



cious than the tranverse, by the yielding of the os 
coccygis and the sacro-ischiatic hgaments, — the antero- 
posterior admitting the greatest enlargement, and being 
the greatest diameter of the outlet of the pelvis, while 
the hisischiatic is the least. Dr. Rigby, however, makes 
the antero-posterior diameter only three and one-eighth 
inches, but admits that it may be lengthened to four 
and one-eighth inches, by the yielding of the coccyx; 
at the same time he maintains that, even with this 
forced extension, the antero-posterior diameter is barely 
equal to the oblique diameters. But Dr. Rigby is an 
advocate of the ohlique theory of the mechanism of labor 
(to be discussed in a future chapter), and this theory 
requires, decidedly, the amplest capacity in the direction 
of these diameters. 

The inferior strait has its plane^ as well as the supe- 
rior; but where is it and how shall it be represented? 
It is manifest that it cannot be represented by a piece 
of pasteboard, fitted to such an irregular aperture. The 
attempt to make such a "fit," would, indeed, be found 
a difficult, if not an impracticable, undertaking. M. 
Cazeaux (1) proposes to solve the difiiculty by consider- 
ing the coccy-pubic diameter as the representative of 
the plane in question. This being assumed, he pro- 
ceeds to determine the direction of this line, and, conse- 
quently, of the plane of the inferior strait. According to 
most French authors, he observes, this plane is slightly 
oblique from helow upwardy and from hehind forward, 
so as to meet the plane of the superior strait anterior to 



(1) Traits Theorique et Pratique de I'Art des Accoucliemens, 
20. 



OBSTETRIC PROPERTIES OF THE PELVIS. 



the s}Tiipliysis pubis. M. Cazeaux refers to the numer- 
ous researches of M. Nsegele, according to which the 
points of the coccyx is placed eight or ten hues higher 
than the summit of the pubic arch, and consequently 
the coccy-pubic diameter is slightly oblique from above 
doimward^ and from hehind fonuard. But the remark 
of M. Yelpeau, that during labor (the only condition 
when it is a matter of any consequence to determine 
the direction of this plane), the point of the coccyx is 
pushed downward and backward by the passage of 
the head, to a level with, if not lower than, the inferior 
part of the symphysis pubis, satisfies M. Cazeaux that 
the plane of the inferior strait is somewhat obHque from 
'below iipivard and from behind forward. 

M. Duges (1), to whom we are indebted for the best, 
though briefest, exposition of the obstetric properties 
of the pelvis, has, in my opinion, removed the difficul- 
ties which embarrassed other authors, by proposing to 
divide the inferior strait into two nearly equal parts, 
one anterior and the other posterior, which meet upon 
the tuberosities of the ischia. The anterior division he 
caUs the vulvar^ the posterior the coccy-perineal, space, 
and these may be represented by two pieces of paste- 
board, — one of which fills up the pubic arch, and the 
other, the posterior vacuities of the pelvic outlet, — 
which meet and are united opposite the ishiatic tuber- 
osities. These pieces of pasteboard, it is evident, will 
form two planes with opposite inclination. Tracing 
them from their junction, the posterior looks upward 



(1) Manuel d'Obstetrique, on Traite de la Science et de I'Art 
des Accoiicliemens, deuxieme edit. Paris, 1830. 



10 RUDIMENTS OF PARTURITION. 



and lachvard, and the anterior, vpivard and forward, 
I am far from agreeing with M. Cazeaux, that this only 
comphcates the question to no useful purpose; on the 
contrary, complication is avoided by considering, as M. 
Duges does, the posterior division as merely a prolon- 
gation, by soft parts, of the posterior wall of the pelvic 
excavation, while the anterior division alone, the vulvar 
sj)ace, is the true plane of the inferior strait. 

The plane of the inferior strait, as thus explained, 
has a much greater inclination upward and fonuardy 
than is allowed by Cazeaux, or any other writer besides 
M. Duges. Its inclination is, in fact, so great that, if 
prolonged above the pubes, it forms by its junction 
with the plane of the superior strait nearly a right an- 
gle, and makes with the axis of the body, tipivard and 
forward, an angle of about forty-five degrees. 

Concerning the axis of the inferior strait, the same 
difficulty has been experienced by authors as in rela- 
tion to its plane, because the direction of its plane de- 
termines, of course, that of its axis. Thus, M. Vel- 
peau asserts that "the axis of the inferior strait is 
represented by a straight line drawn from the interior 
of the pelvis, and cutting the middle of the coccy-pubal 
diameter at right angles; the upper extremity of this 
line most commonly rises as high as the sacro-vertebral 
angle, and sometimes is found to be even parallel with 
the spinal column, and may approach even nearer to the 
axis of the superior strait in very many instances, as is 
proved by the late researches of Professor Nsegele, and 
as I have ascertained for myself" (1) 

(1) Elementary Treatise on Midwifery, translated by Professor 
Meigs. Third Am. edit. Philad., 1845, p. 36. 



OBSTETRIC PROPERTIES OF THE PELVIS. H 



Again. As to the axis of the superior strait, M. 
Moreau's account agrees with that which I have given; 
but with regard to the inferior strait, he declares that 
its axis is represented by a line drawn from the sacro- 
vertebral angle, and that it is parallel to the axis of 
the hodu, having but a slight obliquity forward, and 
forming a very obtuse angle by its intersection of the 
axis of the superior strait (1). 

Having agreed with M. Duges as to the true plane 
of the inferior strait, I cannot, of course, concur with 
MM. Velpeau and JMoreau on this point. The axis of 
the inferior strait has a much more considerable inclina- 
tion forward than they represent; it is, in fact, a line 
passing from the liolloto of the sacrum through the cen- 
ter of the vulvar space, and makes with the axis of the 
body, upward and forivarcl, an angle of one hundred 
and thnty-five degrees. It deviates from the axis of 
the body, then, forty-five degTees, instead of being par- 
allel with it, and makes, by its intersection of the axis 
of the superior strait, nearly a right angle instead of a 
very obtuse one. 

The sum of what has now been said of the planes of 
the two straits, divested of mathematical lines and 
angles, may be thus stated: the plane of the superior 
strait inclines doiumuard and forward; that of the infe- 
rior strait, traced likewise from behind, inchnes upward 
and forward, — and the degree of their inchnation is 
equal, that is, the latter rises as much as the former 
dips. 

In relation to the axes of the straits, it may, mih 

(1) Traite Pratique des Accouchemens, Tom. I, p. 28. 



12 RUDIMENTS OF PARTURITION. 



equal freedom from mathematical teclinicality, be stated, 
that the axis of the superior strait, traced from without 
the pelvis inwardly, is dkected doiunivard and hack- 
ward; while the axis of the inferior strait, traced from 
within outAvardly, is downward and forward. 

Thirdly. The loelviG excavation is^ as M. Duges has 
said (1), a cylindroidal canal, with a bold curvature for- 
ward, and cut perpendicularly to its axis at its two ex- 
tremities or apertures, and hence the shortness of its 
anterior wall, compared with the posterior. The ante- 
rior and posterior walls have a curvature corresponding 
to that of the excavation; but the lateral walls, formed 
chiefly by the ischia, incline toward each other as they 
descend, insomuch that they are nearer, by an inch, at 
the inferior strait than at the superior. These, accord- 
ing to many authors, are the inclined flancB of the pel- 
vis, which, by their direction doiumuard^ fonvard, and 
inward, conduct the vertex of the child's head toward 
the symphysis pubis, as it passes through the excavation. 

No such rotation takes place in fact, during the de- 
scent of the head, as I shall have occasion to show, when 
the mechanism of labor is treated of 

Other authors, again, as MM. Moreau, Yelpeau, etc., 
declare that the pelvis has four planes, inclined toward 
each other at their points. "Suppose," says M. Yel- 
peau, "a vertical cut, which should divide the lesser 
basin into four equal parts, there would be found four 
such planes. The two anterior inclined planes comprise 
a portion of the lateral regions and the whole of the an- 
terior region of the excavation; the two posterior are 



(1) Op. Cit. 



OBSTETRIC PROPERTIES OF THE PELVIS. 13 



formed by the front of the sacrum and coccyx by the 
sciatic ligaments and notches^, and the sacro-iliac articu- 
lations " (1). 

It is evident that, according to this view, the entire 
canal of the pelvis is nothing but a conjunction of in- 
clined planes, and I am not able to perceive either its 
conformity to nature or practical utility. There are, 
however, four planes belonging to the pelvic excavation^ 
but these are to be found only on its sides^ each side 
possessing two. If the internal surface of either ischium 
be carefully examined, it will be seen that a slight 
ridge or rising of the bone may be traced from the origin 
of the spinous process obliquely upward and forward 
toward the ileo-pectineal eminence. This rising, on 
each side of the pelvis, together with the spinous pro- 
cess, divides an anterior inferior inclined ])lane (which 
looks forward and outward), from a posterior superior 
plane^ looking lackward and imvard toward the hollow 
of the sacrum. There is, therefore, a double-inclined 
plane on each side of the excavation, as M. Duges has 
pointed out ; and these favor the rotatory movement of 
the head, which does reaUy take place when it reaches 
the inferior strait, — the occiput gliding upon one of the 
anterior inferior planes, while the forehead moves over 
the surface of the diagonally opposite posterior superior 
plane. 

The configuration of the walls of the excavation hav- 
ing been explained, we have next to inquire into its 
dimensions, which merit special notice, notwithstanding 
" it has usually been deemed sufficient," as Dr. Davis 

(1) Op. Cit. 



X4 RUDIMENTS OF PARTURITION. 



declares (1), " to give the diametrical dimensions of tlie 
pelvis only at the brim and outlet." In this inquiry, 
the same diameters may he ascribed to the excavation 
as belong to the straits. 

It is obvious that the antero-posterior diameter, mea- 
sured from the inner and inferior part of the symphysis 
pubis to the middle of the concavity of the sacrum, is 
longer than the corresponding diameter of either strait. 
This diameter is usually reckoned to be five inches. It 
is equally evident that the transverse diameter is sJiorter 
in proportion to the depth at which it is taken, because 
the lateral walls incline inward, and approach an inch 
nearer to each other at the inferior aperture. But con- 
cerning the oblique diameters, there may be ground for 
difference of opinion, and accordingly while M. Moreau 
avers that they successively diminish as we descend into 
the excavation, Dr. Higby maintains that they are even 
more capacious than the antero-posterior. To the latter 
he allows but four and one-eighth inches, while to the 
former, " drawn from the center of the free space formed 
by the sacro-ischiatic notch and ligaments on one side 
to the foramen ovale of the other," he allows five and a 
half inches (2). 

Dr. Rigby is chargeable with palpable inconsis- 
tency in the account which he gives of the pelvic diam- 
eters. At the superior strait, he agrees with all writers 
that the transverse diameter is shortened by the soft 
parts, situated at its extremities ; nay, he asserts that 



(1) Elements of Obstetric Medicine: Second edition. London, 
1841. 

(2) System of Midwifery : Philadelphia edition, 1841, p. 20. 



OBSTETRIC PROPERTIES OF THE PELVIS. 15 



the "large masses of the psoas magniis and ihaciis in- 
ternus, besides other muscles of inferior size," reduce 
this diameter so that it is but little more than the an- 
tero-posterior. This, he thinks, holds good, especially 
during labor, because "these muscles being thrown into 
powerful contraction, their bellies swell and thus tend 
stni further to diminish its length." 

But the " free spaces" of the sacro-ischiatic notches 
and foramina ovalia are also occupied by muscles, which 
have "belhes to swell" as well, though not so consid- 
erably as the muscles of the brim. What spell, less 
potent than the oblique theory of parturition, could 
transform these into "soft yielding textures," receding 
before pressure, as they are ascribed to be by Dr. 
Rigby? 

We conclude, therefore, that the utmost that can be 
conceded is, that the oblique diameters of the excavation 
are equal to those of the superior strait (probably they 
are rather less), and of course they are shorter than the 
antero-posterior diameter. They are, nevertheless, 
more capacious than the transverse diameter, which, as 
has been already stated, is abbreviated by the approxi- 
mation of the lateral walls toward each other. 

We have, lastly, to inquire into the axis of the exca- 
vation, more famous than the axis of either the supe- 
rior or inferior strait, because it indicates more precisely 
the route pursued by the fetus, in its peregrination into 
this breathing world. The axis of the excavation is a 
line traversing its center ; and as the excavation has a 
curvature corresponding to that of the sacrum, coccyx 
and perineum, it is manifest that its axis can only be 
represented by a line with a similar curvature. To de- 



16 RUDIMENTS OF PARTURITION. 



termine this axis with precision, the method of M. Caz- 
eaiix is good, as far as it goes, which is to draw, from 
several points of the curvature of the sacrum, Hnes at 
right angles with its surface at such points, and extend 
these lines to the posterior face of the symphysis pubis. 
These Hues will represent so many planes of the exca- 
vation, and if then a perpendicular is let fall upon each 
of them, which shall pass through its middle, these per- 
pendiculars will represent the axis of each of the planes. 
It will be easy to see, observes M. Cazeaux, after this 
double operation, that all these axes are confounded, and 
that their union forms a curved hne, whose concavity 
looks forward, whose convexity is parallel with the an- 
terior face of the sacrum, and whose extremities are 
confounded with the axes of the superior and inferior 
straits. To make a full representation of the axis of 
the excavation, according to the view entertained by 
myself, it is only necessary to extend it downward to 
the true plane of the inferior strait, as already ex- 
plained. 

In considering this axis, it is easily discovered that 
it is not the arc of a circle, as professor Carus describes 
it, and after whom it has been called Carus's curve. 
Professor Meigs makes frequent mention of Carus's 
curve, in his pleasant book, entitled, "Females and 
their Diseases," and gives the following directions for 
projecting it. "Bisect a dried pelvis from front to rear; 
set one leg of a compass on the symphysis pubis; open 
the compass two or two and a quarter inches, equal to 
the semi- diameter of the superior strait measured from 
pubis to sacrum; then describe with the free leg an 
arc of a circle, commencing at the plane of the upper 



OBSTETRIC PROPERTIES OF THE PELVIS. I7 



strait and terminating before and below the crown of 
the pubal arch." This is truly Carus's curve, but it is 
not the axis of the excavation, coincidently with which 
the center of the fetal head moves, in passing through 
the pelvis, in labor, and down which the womb slides 
in prolapsion, as the learned Philadelphia professor al- 
leges. The veritable axis of the excavation is nearly 
a straight Hue, where it corresponds to the first two 
vertebrae of the sacrum, as M. Cazeaux has well ob- 
served, because these make nearly a straight line, and its 
curvature is below where it corresponds to the last three 
vertebrse of the sacrum, and greater still as it comes 
forward toward the axis of the inferior strait, so that 
the head of the fetus, in following this axis, must strike 
against the lower part of the sacrum before it begins to 
move toward the vulva. 



18 RUDIMENTS OF PARTURITION. 



CHAPTER II. 
OBSTETRIC APTITUDES OF THE FETUS. 

Under the title of obstetric aptitudes of the fetus, 
will be considered its attitude and situation in the cavity 
of the uterus, and also its dimensions, and structure. 
First: Its attitude. — At the completion of utero-gesta- 
tion, the fetus is, on an average, eighteen or twenty 
inches in length, measured from the summit of the head 
to the heels ; while the cavity of the uterus, when com- 
pletely expanded, does not exceed twelve inches in 
length, by nine in its greatest transverse diameter, and 
six in its antero-posterior. It is, then, obvious that the 
fetus cannot be lodged in this cavity in a state of exten- 
sion, and accordingly it is folded up by the flexion of its 
thighs upon the abdomen, and the legs upon the thighs, 
the head upon the breast, and the arms are closely ap- 
phed to the sides, with the forearms crossed upon the 
chest. In this compact form, its size is not dispropor- 
tioned to the capacity of the uterine cavity, to which 
it is further adapted by its ovoidal figure corresponding 
to the shape of this cavity. 

This apparent packing of the fetus, in order that it 
may occupy the least possible space, is not produced by 
the want of room in the uterus; for, it is observable at 
all stages of gestation, — in the early periods, when its 
size, compared with the cavity, is small, as well as at a 
more advanced period, when its comparative as well as 



OBSTETRIC APTITUDES OF THE FETUS. 19 



absolute size is great. At no period is it crowded, and 
constrained to assume its peculiar attitude. The fetal 
attitude must, therefore, be regarded as a curious instance 
of adaptation of the several parts of a complicated pro- 
cess to each other. 

Secondly: In considering the fetus, thus folded up, in 
reference to its dimensions and structure, we may, with 
M. Moreau, divide it ideally into three distinct parts, 
viz: 1. The cephalic extremity, formed by the head 
alone. 2. The pelvic extremity, including both the pel- 
vis proper and lower extremities. 3. An intermediate 
part, formed by the trunk, exclusive of the pSvis. 

First. The cephalic extremity or head must be re- 
garded as the most solid and voluminous part of the 
fetus ; and on this account, as well as the greater fre- 
quency of its presentation in labor, deserves the particu- 
lar study of the accoucheur. An accurate knowledge of 
its structure, form, and size, is, indeed, indispensable to 
a correct understanding of the mechanism by which the 
fetus comes into the world. 

The head includes the cranium and face, and each 
of these divisions deserves the notice of the obstetrical 
student, on account of some peculiarities of structure in 
the fetus. 

The cranium may be subdivided into two parts, — 
one superior, convex, bulging at its sides, and measuring 
more antero-posteriorly than transversely, — which is its 
vault. The other, inferior, flat, narrower, and shorter, 
which sustains the first, and is, therefore, its hase. Six 
distinct bones enter into the construction of the cranial 
vault, viz., the two parietal, the superior portion of the 
occipital, the squamous portion of the tvjo temporal, and 



!>0 RUDIMENTS OF PARTURITION. 



the frontal bone. The os frontis is, however, usually 
divided into right and left halves, and seven bony pieces 
might, therefore, be enumerated as belonging to the vault 
of the cranium. A greater number of osseous pieces 
c^ompose the base of the cranium ; but these need not be 
mentioned, for they possess no obstetric interest, being 
deeply covered by soft parts-, and never forming the 
presenting part of the child. 

The imperfect ossification of its several constituents 
is the most remarkable, and, in a practical point of view, 
the most interesting, feature of the superior portion of 
the craniAn. In consequence of this, considerable inter- 
vals are left between the bones, in the direction of the 
future sutures of this part of the head. These mem- 
braneous interspaces have usually been denominated, in 
advance, sutures, not however, with strict propriety of 
speech ; I prefer designating them, as M. Moreau has 
proposed, by the term " commissures." The parietal 
bones are, in the fetal skull, separated from the os frontis 
by the coronal commissure, and from the occiput by the 
lanibdoidal, while themselves are parted by the sagiital 
commissure, which derives its name as Dr. F. Rams- 
botham vouchsafes to inform us, from its being fancifully 
supposed to be situated between the lambdoidal and 
coronal, as an arrow is placed in a strung bow(l). The 
comparison is not, after all, so fanciful as to the fetal 
skull, for, the sagittal commissure extends to the root of 
the nose, dividing the two pieces of the frontal bone, and 
thus, like an arrow, projects beyond its bow. It is bet- 
ter, with most authors, to regard this as an extension of 

(1) Process of Parturition ; New Phila. ed,, 1845, p. 31. 



OBSTETRIC APTITUDES OF THE FETUS. ' 21 



the sagittal commissure, tliau to call it, as Dr. Ilamsbo- 
tham does, the frontal 

But there are other and larger soft places in this part 
of the fetal cranium, called fontanels, and produced by 
default of ossification at the angles of the bones. Two 
of these only are worthy of any special notice. One is 
found at the intersection of the sagittal and coronal 
commissures, and the other at the posterior extremit}' 
of the sagittal, where it meets the lambdoidal. The 
former is the anterior or hregmatic fontanel, which is 
distinguished by its quadrangular shape, and the open- 
ings at its angles caused by the entrance of the coronal 
and sagittal commissures. It is, besides, the largest of 
the fontanels. The latter is the posterior or occipital 
fontanel, which is of a triangular figure, and has, like- 
wise, openings at its angles caused by the sagittal and 
lambdoidal commissures. It is of the utmost impor- 
tance that the obstetrical practitioner should be able to 
recognize these fontanels by the sense of touch alone, 
and this he wiU be enabled to do by a little care and 
attention. 

The construction of the cranial vault (the most volu- 
minous part of the head), by separate bony pieces, with 
such large interspaces, is evidently calculated to facili- 
tate its passage through the pelvis in childbirth. There 
are, perhaps, few labors in which these bones ar^e not 
made to approach each other more closely, and, in some 
instances of disproportion, their edges overlap, so a.s 
materially to alter the form of the head. We are not, 
however, to suppose that the absolute size of the head 
can be sensibly diminished. If it be reduced in one 
direction, it is elongated in another to make room for its 



22 RUDIMExVTS OF PARTURITION. 



contents, which are nearly incompressible. It deserves 
to be remarked, in connection with this, that the pulpy 
and semi-organized condition of the brain of the fetus 
enables it to suffer such compression as alters its form, 
with comparative impunity. At the same time, it is not 
improbable that, as has been conjectured, this compres- 
sion produces such a degree of stupefaction as renders 
the fetus insensible, and prevents it from injuring the 
maternal structures by the violence of its struggles. 

In reference to its structure, the face of the fetus is 
not entitled to any very special notice. Composed of 
the same bones as in the adult, it is only remarkable 
for its comparative diminutiveness, so that it detracts 
from the regular figure of the head but little more than 
any other of its regions. 

The sJiape of the fetal head has been variously de- 
scribed by obstetrical writers. M. Duges, following 
Levret in this particular, represents it as a conoid^ — of 
which the face is the base, and the occiput the summit. 
But it is more correctly represented by M. Capuron as 
an ovoid^ and having, therefore, tivo extremities^ — one 
large, obtuse, and round, formed by the superior portions 
of the OS occipitis; the other smaller, and more acute, 
formed by the chin. 

Most of the French authors describe five distinct 
regions as belonging to the head; and M. Moreau fixes 
their metes and bounds with scrupulous precision. But, 
in a practical point of view, it is scarcely worth while to 
preserve more than two of these regions, viz., the vertex 
and face^ because these alone offer themselves at the 
supeiior strait in head presentations, or if one of the 
temples is found there, it is but a rare perversion of a 



OBSTETRIC APTITUDES OF THE FETUS. 23 



vertex presentation, and can easily be detected by feel- 
ing the ear, which is its only distinguishing mark. 
Enghsh writers, using the term " vertex " according to 
its strict import, apply it to that part of the head where 
the hair grows in a whirl, which is nearly over the pos- 
terior fontanel ; hence, Dr. F. Ramsbotham affirms " it 
is not perfectly correct to say that the vertex is the 
presenting part; " while he allows that "for all practical 
purposes it is enough to describe the vertex as the point 
of presentation." There can surely be no objection, 
however, against enlarging the signification of the term, 
and making it equivalent to the summit or top of the 
head, as M. Duges and others have done. In this sense 
it will be constantly used in this work; and it will, there- 
fore, be understood to include the anterior and posterior 
fontanels, and the parietal bones, fi'om then protuber- 
ances to the sagittal commissure. 

The dimensions of the fetal head are measured by 
certain imaginary lines, called its diameters, which have 
been as variously enumerated as denominated by au- 
thors. The following may be considered essential to a 
correct explanation of the mechanism of labor in vertex, 
and face presentations. In vertex presentations : 1. The 
occipito-frontal diameter, extending from the occipital 
to the fi^ontal protuberance, measuring four and one- 
fourth to one-half inches; this I shall call, also, the great 
diameter of the head. 2. The cervico-hregmatic, from 
the junction of the cervix, or hinder part of the neck, 
with the occiput, to the anterior fontanel or bregma. 
3. The liparietal^ fi'om one parietal protuberance to the 
other; the latter two are nearly equal, and, measuring 
three and a half inches, may be called small diameters of 



24 RUDIMENTS OF PARTURITION. 



the head. In Hice presentations: 1. The fronto-?nenial 
from the top of the forehead to the chin (mentimi), four 
inches, rather less than the great diameter, but exceed- 
ing the small. 2, The gutturo-bregmatic, from the 
throat (guttMr), just above the larynx, to the anterior 
fontanel, — three and a half inches, and consequently a 
small diameter. 3. The hi malar, from one malar bone 
to the other, — three inches, and of course the little 
diameter. Besides these, all authors, without exception, 
mention another diameter, with which they usually, in- 
deed, head the catalogue, — viz., the ocdpito-mental, from 
the posterior fontanel to the chin, and measuring five 
inches, which they call the longest diameter of the head. 
But I prefer considering this as the axis of the head, 
under which name it will be referred to, though I may 
occasionally call it likewise the occipito-mental diameter. 
To each of these diameters a circumference may be 
given by describing a circle from their middle with a 
radius of half the diameter. But there is no practical 
utility in thus multiplying the circumferences of the 
fetal head : two only can be advantageously referred to 
in considering the passage of the head through the pel- 
vis, in vertex cases. These are: 1. The occqoito-froiital 
circumference, which passes horizontally, a little below 
the extremities of the lifarietal diameter, and divides 
the vault from the base of the cranium, measuring thir- 
teen inches, which I shall call, also, the great circumfer- 
ence. 2. The cervico-bregmatic circumference, passing over 
the extremities of the biparietal, as well as the cervico- 
bregmatic diameter, belonging equally to both. This I 
shall call, also, the lesser circumference of the fetal head, 
its measure not exceeding eleven inches. The fronto-men- 



OBSTETRIC APTITUDES OF THE FETUS. 25 



tal and gutturo-bregmatk circumferences will be easily 
comprehended, should there be occasion to refer to them 
in describing the mechanism of face presentations. 

The movements which the head of the fetus can be 
made to execute safely, by virtue of its connection with 
the spinal column, are deserving the attention of the 
obstetrical student. These are flexion, extension, rota- 
tion, and lateral inclination. The first two are per- 
formed by the articulation of the occiput with the 
atlas, and the laxity of the ligaments in the fetus per- 
mits them to be carried to a greater extent than in the 
adult; — there being, m fact, no Hmit even to extension, 
except the check received by the occiput from the pos- 
terior part of the thorax. Hence, face presentations, 
which imply extreme extension, are not such constrain- 
ed positions for the fetus, as we might imagine from the 
awkwardness, or rather impossibility, of such a move- 
ment in ourselves, notation is executed by the artic- 
ulation of the atlas with the dentatus, which limits its 
extent to a quarter of a circle, beyond which it cannot 
be forced without risk of fatal laceration. Hence, in 
the operation of turning, or in the management of nates 
presentations, the practitioner should take care not to 
rotate the child's body beyond this limit, lest the head, 
yet contained in the uterus, might not participate in 
the rotation, and the child be destroyed by the injury 
inflicted on it. There is no special articulation for lat- 
eral inclination : it is performed by the yielding of the 
ligaments and fibro-cartilages of all the cervical verte- 
brge, and can be carried so far as to place the side of 
the head upon either shoulder. 

Secondly, The ^^elvic extremity of the fetus offers 



RUDIMENTS OF PARTURITION. 



much less to interest us than the cephahc. Its form is 
spheroidal, and between its two hemispherical surfaces 
there is a cleft in which the anus and genital organs are 
found. It is to be observed that the pelvis proper of 
the fetus is very small, being, in fact, almost in a rudi- 
mentary state; but its magnitude, obstretically consid- 
ered, is increased by the articulation of the inferior 
extremities with it, and the peculiar manner in which 
these are folded upon it. Two diameters only are as- 
cribed to it, viz., the transverse and antero-^oosterior. 
The transvere extends from one ilium to the other, 
and measures about four inches. The measure of the 
antero-posterior diameter is not constant, being more or 
less according as the inferior extremities make a part of 
it by maintaining their usual position, or depart from 
it, by the legs being extended upon the abdomen. In 
the first case, the antero-posterior diameter is greater, 
in the second case less, than the transverse. 

Composed of a considerable number of pieces, which 
are but imperfectly ossified, some of which are even in 
a cartilaginous state, the pelvis of the fetus may be 
somewhat reduced in volume, by the pressure it expe- 
riences in its passage into the world. The softness and 
flexibility of the parts in connection with it, allows this 
extremity of the fetus to be molded to the shape and 
dimensions of the maternal pelvis, without much injury 
to thek structures. 

Thirdly. The tninJc of the fetus, though quite 
bulky, is composed of a great number of pieces, some of 
which, viz., the ribs and sternum, are in a cartilaginous 
and imperfectly ossified condition. It presents a uni- 
form curvature forward, produced by the flexion of the 



OBSTETRIC APTITUDES OF THE FETUS. 27 



spine, which differs from that of the adult in offering 
but a single curvature, instead of three, in opposite di- 
rections. The posterior surface of the trunk is rendered 
much more prominent and regularly convex by this an- 
terior flexion of the spine. To the superior or thoracic 
portion of it are reckoned two diameters : 1. The trans- 
verse or hisacromial, which extends across from one 
shoulder to the other, and measures four and a half 
inches. 2. The antero-iwsterior or dor so-sternal^ from 
the spinous apophysis of the last dorsal vertebrae to the 
ensiform cartilage of the sternum, measuring three and 
a half inches. The mobility of the shoulders and ribs, 
together with their compressibility, easily allows, as M. 
Moreau observes, the bisacromial diameter to be reduced 
to three and a half inches, vidiile the flexibility of the 
spine enables the entire trunk to accommodate itself to 
the curvature of the pelvic canal during labor. 

It remains to inquire into the situation of the fetus 
in utero. It has already been stated that the size and 
figure of the fetus are adapted, by reason of its peculiar 
attitude, to the capacity and shape of the cavity in 
which it is contained. Let us examine this adaptation 
a little more particularly. The cavity of the gravid 
uterus is of an ovoidal figure, the large extremity of 
the ovoid being at the fundus and the small at the cer^ 
^ix. The figure of the folded fetus is likewise ovoidal, 
its nates being the large, the head the small, extremity of 
the ovoid. It is obvious, then, that the fetus would be 
most commodiously situated with its head toward the 
cervix, and its nates toward the fundus, uteri. 

Again. The transverse dimension of the uterine 
cavity is greater than its antero-posterior, while, on the 



28 RUDIMENTS OF PARTURITION. 



other hand, the antero-posterior dhnension of the fetus, 
viz., fi'om its back to its abdomen, is greater than its 
transverse, viz., from side to side. The fetus Avould, 
therefore, find more room in its lodging, with its back 
toward one side of the uterus, and its abdomen and 
flexed members toward the other. But the remarkable 
convexity of its back needs a corresponding concavity 
of the uterus to accommodate it, and this is offered by 
the anterior wall of the uterus, which is more concave 
than the posterior. If, therefore, its back were directed 
forward, it would be accommodated in this respect. 

Now, the most usual situation of the fetus in utero 
is such as to put it in possession of all these comforts. 
Its head is toward the cervix, its nates toward the fun- 
dus, while its back is turned, neither laterally nor ante- 
riorly, but toward the left anterior or right anterior por- 
tion of the cavity of the uterus. This accounts for the 
more frequent presentation of the head at the time of 
parturition; but, it may be inquired, what causes the 
fetus to assume, and generally to maintain, this position 
in the womb, during the period of gestation? This 
question has excited the curiosity, and exercised the 
ingenuity, of medical philosophers in ancient and mod- 
ern times, and still it can hardly be considered as satis- 
factorily answered. It was formerly believed that the 
fetus sits in the uterus, with its fore parts dkected 
toward the mother's abdomen, until the seventh or 
eighth month of pregnancy, when, from the develop- 
ment of the head, and its preponderance over the rest 
of the body, it turns topsy turvy, the head falling for- 
ward and downward, while the nates rise to the fundus 
uteri. 



OBSTETRIC APTITUDES OF THE FETUS. 29 



This opinion was completely refuted by the observa- 
tions of Delamotte, Smellie, and Baudelocque, and is 
now universally abandoned. But it is still commonly 
taught that the weight of the head, compared with the 
rest of the body, at all stages of fetal development, is 
the cause of the great frequency of its presentation. 

This purely physical theory has been combated, and 
in my opinion, satisfactorily refuted, by M. Paul Du- 
bois (1 ). Whether the explanation which he has offered 
in lieu of it, is to be regarded as equally satisfactory, 
may admit of doubt; but surely his researches are enti- 
tled to more notice than they have received, on account 
of the valuable facts which have been disclosed by 
them. I shall, therefore, offer no apology for present- 
ing my readers with an abstract of his interesting 
memoir. 

In opposition to the theory in question, M. Dubois 
alleges: 

First. If we take a dead fetus, from the fourth to 
the ninth month of gestation, and put it, by means of 
bandages, in the attitude natural to it in the uterus, it 
may be plunged into tepid water without the head 
sinking more rapidly than the rest of the body. This 
is the ordinary result, when vessels are used for the 
experiment as nearly as possible the size of the uterus, 
at the different periods of gestation to which the fetus 
belongs. But the experiment is rendered more con- 
vincing, if the fetus be plunged into a larger quantity 

(1) " Memoire sur la cause des presentations de la tete pendant 
r accouchement et sur les determinations instinctives ou volun- 
taires du foetus humain." — {Mtmoires de V Acaoleinie Roy ale de 
Medicine, tome deuxieme. p. 266. 



30 RUDIMENTS OF PARTURITION. 



of water, — into a bathing vessel, for example, — when, 
falling more slowly and through a larger space, time is 
allowed for the head to descend foremost, if it be really 
heaviest; but it is found, in fact, that every part of the 
fetus descends with equal rapidity, the trunk preserving 
the horizontal position it had w^hen first plunged into 
the water, and the back or a shoulder first reaching the 
bottom of the vessel. 

This experiment, frequently repeated, constantly 
yielded the same result, which is no more than reason- 
ing ought to have led us to expect, — for, if the fetal 
ovoid be divided into two equal parts, one consisting of 
the head and superior extremities, the other of the ab- 
domen and inferior extremities, their weight is about 
the same. If the head contain the brain, greatly de- 
veloped, the abdomen contains the liver, equally large, 
besides the meconium, sometimes accumulated in large 
quantity in the intestines, and a certain quantity of 
urine in the bladder. 

Secondly. According to the hypothesis that the 
laws of gravity preside over the position of the fetus in 
utero, the head ought to be more irresistibly carried 
toward the os uteri in the earlier periods of gestation, 
when it is relatively more developed, when also the 
cavity of the uterus is proportionably larger, and the 
quantity of liquor amnii comparatively greater. But 
the reverse is true: presentations of the cephalic ex- 
tremity are proportionally less frequent in the earlier 
than in the latter months of gestation. In confirmation 
of this, M. Dubois appeals to observations made in the 
Paris Maternity during four consecutive years, from 
which it appears, that in the year 1829, thirty children 



OBSTETRIC APTITUDES OF THE FETUS. 31 



were born before the seventh month, of which twenty- 
two presented the vertex, seven the pelvic extremity, 
and one the right shoulder. In 1830, thirty-five chil- 
dren were born before the seventh month, of which 
sixteen were vertex presentations, eighteen pelvic, and 
one shoulder. In 1831, of tiuenty-three children born 
at the same period of pregnancy, thirteen were vertex, 
nine nates, and one left-shoulder presentations. In 
1832, of thirty-four children, not arrived at the seventh 
month, fourteen were vertex, seventeen nates, two shoul- 
der, and one expelled enveloped in the membranes, its 
position not ascertained. Total number of premature 
births, one hundred and twenty-one, of which sixty-five 
were vertex, fifty-one nates, and five shoulder presenta- 
tions. The proportion of nates to vertex was, therefore, 
as four to five, instead of as one to thirty-six, which ob- 
tains at full term, according to Baudelocque's statistics. 

Thirdly. In quadrupeds, the head of the fetus pre- 
sents with as much constancy as in the human species ; 
and yet, on account of the direction of their trunk, the 
ovum or ova, contained in their unilocular or multilocu- 
lar uterus, have nearly a horizontal position in the early 
period of gestation, and, in the latter period, an inclina- 
tion opposite that of the fetus of the human female, 
seeing the fundus uteri comes, by the yielding of the 
abdominal parietes, to be the most dependent part of 
the organ. The head ought, therefore, to be furthest 
removed fi^om the os uteri, on the principles of the phy- 
sical theory. 

If the laws that govern dead matter do not regulate 
the situation of the fetus in utero, M. Dubois concludes 
that those of life do, and that some connection exists 



32 RUDIMENTS OF PARTURITION. 



between the vitality of the fetus and head presentation. 
This conckision is corroborated by the results of his in- 
quiries as to the comparative frequency of head presen- 
tations, where the fetus dies, in the latter months of 
gestation, some time before its expulsion. During the 
four years occupied in his researches, ninetij-six chil- 
dren were born at the JNIaternity, that had died during 
the last two months of gestation ; of these, seventy-two 
presented the head, twenty-two the nates, and two 
the shoulder, making the proportion of nates to vertex 
presentations as one to three and a quarter, which is a 
great increase of the proportion that obtains where liv- 
ing children are born at the same period. These facts 
show the influence of fetal vitality in a strong light, for 
it would not have been surprising if the relative propor- 
tion of vertex and nates presentations had not been 
affected by the death of the fetus at such an advanced 
period of gestation. The force of this remark will be 
acknowledged when it is recollected that in the latter 
months of pregnancy, the fetus is too large, relatively 
to the cavity of the uterus, easily to allow any essen- 
tial change to take place in its situation; and it might, 
therefore, be supposed that whatever position it hap- 
pened to occupy at the time of its death, would be pre- 
served in spite of the disturbing influence of extraneous 
causes. Such causes, — violent exercise, jolting, stoop- 
ing, lifting, etc., for example, — would be more power- 
fully operative upon the dead fetus, were there more 
room in the cavity containing it ; and accordingly it ap- 
pears, from observations collected in the same ample 
field by M. Dubois, that if the fetus die during the 
seventh month, it will be born as often under a nates as 



t 



w 



OBSTETRIC APTITUDES OF THE FETUS.; 33 



head presentation. Thus, in the years 1829, 1830, 
1831, and I'^Zij foiiy-six children, dying in the seventh 
month of pregnancy, were born at the Maternity; of 
these, twenty-one were head presentations, twenty-one 
nates, and four shoulder, — a remarkable result, com- 
pared with that of living children born at the same pe- 
riod of pregnancy ; for, during the same years, seventy- 
three living seven months' children were born, sixty-one 
of whom presented the vertex, ten the nates, and two 
the shoulder. 

These facts leave no doubt of the influence of the 
life of the child over its situation in the uterus ; but if 
it be inquired how is this vital influence exerted, it 
would perhaps be presumptuous to speak with equal 
positiveness. After estabhshing, by a great number of 
observations, the fact that the fetus possesses sensibility 
and performs muscular motions, in consequence of the 
various impressions it receives, M. Dubois contends that 
its voluntary or instinctive movements, in obedience to 
an internal sensation, cause it to occupy the position it 
does. In answer to the question, what is the nature of 
this internal sensation ? he asks whether the abnor- 
mal situation of the fetus, ia which its nates cor- 
respond to the small extremity of the ovum, is incon- 
venient or painful and gives rise to spontaneous move- 
ments to change this position for one of ease, or whether, 
as both extremities of its trunk are best accommodated 
to the form of the ovum, with the nates above and the 
head downward, it is the comfort ( bien-etre ) of this 
situation that determines the fetus to seek and retain 
it ? He does not pretend to decide the question, but 
observes further, that the fetus executes its greatest 
3 



84 RUDIMENTS OF PARTURITION. 



movements with the inferior extremities, and that these 
are easier, more extensive, and less trammeled Avhen its 
pelvic extremity corresponds to the large extremity of 
the ovum, and that possibly this circumstance has some- 
thing to do with the choice of its relations to the 
uterus. 

Whatever may be the cause of the pecuHar situation 
of the fetus in the womb, there can be no doubt but it 
is to be reckoned among the most felicitous of its ob- 
stetric aptitudes. 



THE APPURTENANCES OF THE FETUS. 35 



CHAPTER III. 
OF THE APPURTENANCES OF THE FETUS. 

The fetus does not exist in its mother's womb, in- 
an isolated manner, having no other dependence upon 
her than for lodging, but it draws from her likewise its 
nourishment, and even breathes through her. These 
necessary offices are performed for it, through the me- 
dium of what I have called its appurtenances, namely, 
its membranes, the placeiita, and the umhilical cord, 
constituting together what are commonly called the 
secundines or afterbirth, because they are usually cast 
off after the birth of the child. As obstetricians, we 
are only concerned with these appurtenances of the 
fetus, at the close of gestation, and it is at this advanced 
period I shall consider them, except so far as reference 
to their earher history may be necessary to a correct un- 
derstanding of their structure and uses. 

( A. ) The fetal membranes. These consist of 
three layers, forming a complete envelop of the fetus, 
and upon the outer surface of one of them the placenta 
is formed, at a certain stage of gestation. The most 
externid of these membranes is the decidual which is 
produced upon the internal surface of the uterus, very 
early after conception, to fit it for the reception and 
nourishment of the ovum, but Avhich, at the period we 



S6 RUDIMENTS OF PARTURITION. 



are now considering, is very much attenuated, every- 
where except in the placenta, to whose formation it 
contributes. The decidua can, in fact, at this period, be 
demonstrated with difficulty, being seen only in shreds 
and patches, as I have, many times, satisfied myself by 
examining recently ejected secundines. It is, therefore, 
no wonder that its existence has been called in question 
by Baudelocque, Capuron, and others. 

The other two membranes, viz., the chorion and the 
amnion^ are the property of the fetus; they are brought 
with the ovum when it enters the cavity of the uterus, 
and their growth keeps pace with the development of 
the fetus. The chorion is the outermost of these, and 
appears, at the period we are contemplating it, Hke a 
membrane of fibrous structure, — possessing considera- 
ble thickness, being smooth, diaphanous, destitute of 
visible bloodvessels, and connected to the amnion and 
vestiges of the decidua by very fine cellular tissue. At 
an earlier stage, its external surface is shaggy, being 
thickly set with viUi, which become vascular; but when 
the placenta is formed upon a portion of this surface, the 
rest of it assumes the smooth, non-vascular appearance 
just described. The innermost layer, the amnion, ap- 
pears to belong to the class of serous membranes. It is 
thinner than the chorion, and has a smooth, polished, 
internal surface, looking toward the fetus and bathed 
by the waters which it secretes, namely, the Hquor am- 
nii. Its union with the chorion, over the internal face 
of the placenta, is so slight that it will generally be 
found detached from it, in a good degree, and lying 
loosely upon it. 

( B. ) The placenta. The placenta is a thick, 



THE APPURTENANCES OF THE FETUS. 37 



spongy, and exceedingly vascular structure, of a circu- 
lar or slightly oval figure, measuring seven or eight 
inches in its greatest diameter, and thinner toward its 
margin or circumference than in its center. It has two 
surfaces, — an external or uterine surface, and an inter- 
nal or fetal one The external surface adheres, with no 
great firmness, to the inner surface of the uterus ; it 
may be connected with any portion of the organ, but 
most frequently it forms its attachment posteriorly and 
at some distance from the os uteri. When separa- 
ted from the uterus, this surface - of the placenta offers 
many smooth lobes, by some called, though improperly, 
cotyledons, and between these, fissures, which have been 
called smiises, in which may be seen, here and there, 
large, smooth openings, communicating with the spongy 
substance of the placenta, through which blood may be 
made to exude by compression. The inte^^nal surface 
of the placenta is more even ; it is covered by the cho- 
rion and amnion, the former being inseparably united to 
it, and exhibits, very conspicuously, the large branches 
of the umbilical bloodvessels, which diverge from its 
center, like the rays of a parasol. 

The placenta is the organ of intercommunion be- 
tween the mother and the fetus. The anatomical struc- 
ture that fits it for such an office is as curious as it is 
interesting, and has not until recently been well under- 
stood. The account which I shall give of it, is taken 
from Weber, a German authority, and is derived from a 
note by Dr. Willis, in his translation of Wagner's 
Physiology, as quoted in Braithwait's Retrospect, Part 
XIII, page 320. According to the views of Weber, 
the placenta consists of a fetal and maternal portion, 



RUDIMENTS OF PARTURITION. 



the former beiiig developed upon a part of the chorion, 
and the latter consisting of the inner and exceedingly 
thin coat of the uterine arteries and veins, that go to 
the placenta. To get a clear idea how these constitu- 
ents are connected to compose such a structure as the 
fully matured placenta, we must consider them sepa- 
rately. And first as to the fetal portion. It has been 
already stated that when the ovum first conies into the 
uterus, its outer membrane, the chorion, is thickly cov- 
ered with villi, which are not at first vascular. These 
vilH are, at that period, nothing more than spongioles, 
which probably absorb nutriment for the embryo from 
the surrounding fluids. But as development progresses, 
they become vascular, and shoot forth as processes from 
the surface of the chorion. These processes, in grow- 
ing, form large and numerously divided stems and 
branches, in the manner of little trees, and are hence 
called dendritic, " Into each of these dendritic pro- 
cesses of the chorion there penetrates a branch of the 
umbilical artery, and a branch of the umbilical vein. 
Both vessels divide into branches in the same manner 
as the process of the chorion in which they run. At 
the extremities of the branched processes of the chorion, 
the divisions of the umbilical artery come together in 
loops or coils ; these coils, however, are for the most 
part not simple ; the same capillary winds several times 
hither and thither, and forms several loops ; — loops are 
also frequently formed by the anastomosing of two 
neighboring capillaries. From these convolutions and 
loopings of the capillaries little thickenings or enlarge- 
ments of the extreme divisions of the processes of the 
chorion are produced. Each particular trunk, with its 



THE APPURTENANCES OF THE FETUS. 39 



divarication of the shaggy chorion, forms a lobe or 
lobule of the placenta, which is covered by the tunica 
decidua, to which many of the terminal branches of the 
chorion will be found to have grown." 

Suppose such a process of growth to have taken 
place from the chorion, without anything on the part 
of the uterus to mate it, it is obvious that among this 
branched work, there would be numerous interstices, 
not occupied by any organic product. But while this 
fetal portion of the placenta is being developed, the ma- 
ternal portion is forming and pushing itself in the oppo- 
site direction. 

This maternal portion of the placenta consists, as 
already stated, of the dehcate, internal coat of the 
uterine veins and arteries, opposite the new fetal for- 
mation, and as it expands, it carries a thin layer of the 
deciduous membrane before it, and becomes molded to 
the interstices of the dendritic processes of the chorion. 
This dehcate vascular coat, with its investing decidua, 
does not fill the interstices, or hardly appreciably di- 
minish their spaces, but, coming in contact with the 
processes of the chorion, furnishes them with a very 
thin covering. The arrangement of the fetal and ma- 
ternal constituents of the placenta is such as would 
result, if we imagine, for the sake of illustration, that, 
prior to the sprouting of the chorion, the uterine vessels 
form, by their protruded internal coat and the help of 
the decidua, one large sack on the inner surface of that 
portion of the uterus, where the placenta is to be, and 
then the dendritic processes of the chorion impinge 
against this sack at various points, and as they elon- 
gate, they invert the sack at these points, bringing it 



46 RUDIMENTS OF PARTURITION. 



into contact with the uterine surface, where the ex- 
tremities of these processes come into contact with that 
surface. 

To render this account still more clearly intelligible, 
we may bon^ow an illustration from Dr. Chowne, a 
writer in the London Lancet. In one of his interesting 
articles, " on the source of hemorrhage in partial sepa- 
ration of the placenta," he uses a glove to represent 
the structure in question, which, as he says, is a very 
humble illustration, but, as a compensation for its hum- 
bleness, has the advantage of its being by no means 
difficult for any one to carry it into efiect. " If, for in- 
stance," Dr. Chowne observes, "he takes his glove, 
and places it on the table with the palm downward, 
and the tips of the fingers toward himself, and then 
puts the points of his own fingers against the tips of 
those of the glove, and pushes them ( the tips of the 
fingers of the glove ) inward, inverting them within 
themselves, until his fingers have pushed them up into 
what might be called the body or hand part of the 
glove, and each finger is enveloped in the inverted fin- 
ger of the glove which it has pushed up before it, he 
produces a representation of the manner in which the 
fetal vessels and the maternal vessels come together, 
while the current in each remains distinct." (1) 

The uterine arteries and veins do not enter the pla- 
centa, and divide into twigs and branches, but immedi- 
ately terminate in a network of vessels, the canals of 
which are of far too large diameter to permit them to be 

(1) Republication of the London Lancet, New American Series, 
March, 1848. 



^ 



APPURTENANCES OF THE FETUS. 41 



spoken of as capillaries, and of which the parietes are so 
thin, that they cannot be shown apart by the most care- 
ful dissection. " This vascular rete," says Weber, "which 
connects the uterine arteries and veins with each other, 
completely fills the spaces between the branched divi- 
sions of the chorion, and the extremely thin parietes of 
the canals of which it is composed, insinuate themselves 
at all points into the most intimate contact with the 
branches and convoluted masses of the capillaries of the 
umbiHcal system of vessels. This network of vessels, 
however, with reference to the passage of the uterine 
arteries into the uterine veins, performs the same office 
as a rete of true capillaries, so that it may be regarded 
as a rete of colossal capillaries." 

That this description may be clearly comprehended, 
it is necessary to bear in mind, that the large uterine 
veins, whose inner, dehcate coats penetrate the placen- 
ta, open by extremely large orifices upon the internal 
surface of the uterus, opposite the placenta, and may be 
easily seen, for some time after parturition, in women 
dying in childbed. These orifices appear to be the ter- 
minations of the veins: they are perfectly smooth, and 
by their oblique manner of piercing the coats of the ute- 
rus, they are partially covered with membranes in the 
form of valves. This is, in fact, the natm^al disposition 
of many of the veins of the uterus, independent of preg- 
nancy, and besides other uses, may be supposed to have 
reference to the pecuhar structure, namely, the placenta, 
which is to be developed, whenever pregnancy takes 
place. Baudelocque (1) describes the fining membrane 

(1) L'Art des Accouchemens, par. 9, 160. 



42 RUDIMENTS OF PARTURITION. 



of the uterus as having so many pores, or openings, that 
it may be said to be reticulated: some of the openings, 
he says, lead to tortuous cavities, called uterine sinuses 
(only another name for veins). There is reason to be- 
lieve, that the menstrual blood escapes through these ori- 
fices, — an idea which is strongly countenanced by an ob- 
servation of a late English writer, Mr. Whitehead, of 
Manchester. The subject of the observation alluded to, 
was a young woman, who died of monorrhagia, and whose 
system appeared, in the post-mortem examination, drain- 
ed of blood. The inner surface of the uterus, after re- 
moving from its cavity a clot of blood, which completely 
filled it, presented, in the language of the author, "nu- 
merous openings scattered over every part of it, obvious 
to the naked view, some being sufficiently large to admit 
a good-sized bristle, or the end of a lachrymal probe. 
The largest and most numerous were at each side of the 
fundus, near the horns of the uterus, and at the contrac- 
ted part of its body near the commencement of the cer- 
vix. The openings had a valved arrangement, a great 
number passing downward toward the cervix, while 
those at the upper part of the organ appeared to pass to- 
ward the fallopian orifices." (1) I do not know that 
there is any such provision made for uterine gestation in 
the disposition of the arteries; but it is well ascertained, 
that the liter o-placental arteries, examined shortly after 
the separation of the placenta, appear to terminate ab» 
ruptly upon the inner surface of the uterus, being yet of 

(1) Causes and Treatment of Abortion and Sterility. Philadel- 
phia : Lea and Blanchard, 1848, p. 51. 



APPURTENANCES OF THE FETUS. 43 



considerable magnitude, and after having made two or 
three close spiral twists upon themselves. 

Although Weber's description of the placenta is ana- 
tomically different from that of John Hunter, it is not 
physiologically oy practically different. It is well known 
that the great EngUsh physiologist taught, that the pla- 
centa is formed entirely by the fetus, and is composed 
principally of the ramifications of its vessels. Into its 
spongy structure, nevertheless, he taught, that the large 
uterine veins and arteries open. The arteries, said he, 
which are not immediately employed in conveying nour- 
ishment to the uterus, go on toward the placenta, and, 
proceeding obhquely between it and the uterus, pass 
through the decidua without ramif)dng, and making two 
or three close spiral turns upon themselves, they open at 
once, and without any diminution of size, into the spon- 
gy substance of the placenta. These curling arteries, he 
describes as being about half the size of a crow-quiU, and 
sometimes larger. The veins of the uterus, appropriated 
to bring back the blood from the placenta, commence, 
according to Mr. Hunter, from this spongy substance hy 
such tuicle heginnings as are more them equal to the si^e 
of the veins themselves. (1) Here, then, we have the in- 
sterstices of the placenta in communication with the arteri- 
al and venous vessels of the mother, whose blood ckculates 
through these interstices, being detached^ as Mr. Hunter 
expresses it, from her common circulation. There is^ 
therefore, in his account, a virtual^ though not an anato- 
mical^ maternal portion of the placenta, and Weber has 

(1) Complete Works of Jolin Hunter; edited by James F. 
Palmer, Vol. lY. ; Observations on the Animal Economy. 



44 RUDIMENTS OF PARTURITION. 



added nothing to our knowledge of the physiology of the 
placenta; he has only taught us, that the placental inter- 
stices, in which the maternal blood flows, are lined by the 
inner coat of the uterine arteries and veins prolonged into 
them, and that, therefore, this blood continues to be held 
in its own system of vessels, and is not extravasated. 

The placenta is deciduous; after the expulsion of the 
child, it, together with the membranes connected with it, 
is easily separated from the uterus and ejected. In this 
respect, as well as in its peculiar structure, there is, I 
beheve, nothing like it to be found in the inferior ani- 
mals, unless it be in the monkey, Avhose secundines, in a 
single instance observed by him, are described by Mr. 
Hunter, as resembhng those of the human female. In 
quadrupeds, or I should rather say more restrictedly, in 
the ruminants, whose gravid uteri I have examined with 
some care, the connection between the fetus and mother 
is formed by the implantation of tufts or tassels of the 
chorion in the cotyledons of the uterus. These cotyle- 
dons are cup-like elevations upon the internal surface of 
the uterus; they are very numerous, being found not 
only in the body of the organ, but also in both horns^ 
even to their termination. They appear to be the natu- 
ral structure of the internal coat of the uterus (I have 
seen them in the calf of six weeks), and are only greatly 
developed by pregnancy. The vascular tufts of the cho- 
rion do not adhere to the cotyledons so firmly but they 
may be eradicated without laceration, and I infer ( for I 
confess I have not happened to witness all the phenome- 
na of parturition in these animals) that they are thus 
detached by the action of the uterus, leaving the cotyle- 



APPURTENANCES OF THE FETUS. 45 



dons, which could not, indeed, be cast off without bring- 
ing an entire coat of the uterus along with them. 

Having unfolded the structure of the placenta, we 
are prepared to understand its uses in reference to the 
fetus. First; it is its organ of respiration. The umbiH- 
eal vessels, already described as terminating in capillaries 
upon the dendritic processes of the chorion, belong ex- 
clusively to the vascular system of the fetus. They con- 
sist of three trunks, two arterial branches of the inter- 
nal ihacs, and one large vein, the umbilical, a branch of 
the inferior vena cava, and have no communication what- 
ever by anastomosis with the bloodvessels of the mo- 
ther. The umbilical arteries convey no inconsiderable 
portion of the blood of the fetus to the placenta, which 
after circulating freely and minutely through it, is return- 
ed to the fetus, not a drop passing into the vessels of the 
mother. "While circulating in the placenta, this blood 
is brought in contact with the blood of the mother, flow- 
ing through the canals of the maternal portion of the 
placenta, or at least nothing intervenes but the thin walls 
of these canals, and the dehcate coats of the fetal capilla- 
ries. The fetal blood is thus enabled to abstract oxygen 
from, and impart its superfluous carbon to, the blood of 
the mother ; and although it may be supposed that this 
vital operation is not as fi-eely performed as in animals 
that inhale atmospheric air, it is at least as advantageous 
an arrangement as the branchial respiration of such as 
inhabit the waters, to which it is, in fact, analagous, — 
fishes getting their oxygen from water, and the fetus 
from maternal blood. 

It deserves to be remarked (and this did not escape 
the sagacity of Mr. Hunter), that the whole constitution 



46 RUDIMENTS OF PARTURITION. 



of the maternal portion of the placenta is calculated to 
produce a slow movement of the blood flowing through 
it: for the utero-placental arteries are coiled where they 
open into it, which diminishes the force of the circula- 
tion, and then when the blood gets into the placenta, its 
impetus is abated by its being diffused through channels, 
incomparably wider than the small arteries through 
which it is received. The motion of the blood is so 
much diminished by this mechanism as, in the opinion 
of Mr. Hunter, almost to approach to stagnation. The 
blood of the mother being detained for a longer time in 
the placenta, permits the fetal capillaries to extract its 
oxygen, and freight its sluggish tide with carbon, more 
perfectly than they could do, were its motion as rapid 
here as in other parts of the mother's system. 

In animals with cotyledons instead of a placenta, the 
arterialization of the fetal blood is accomplished by the 
juxtaposition of the fetal with the maternal capillaries in 
the cotyledons, — a disposition not near so favorable to this 
vital function as the placentary, both because there is less 
maternal blood in the same area, and its motion is more ra- 
pid. Hence, as I judge, the necessity of a larger extent of 
uterine surface, and a great number of cotyledons, to ob- 
tain which, horns are appended to the uterus. In the 
human female, such a structure of the uterus w^ould not 
have been compatible with the symmetry and beauty of 
her form. The womb must occupy as httle space and 
be as little conspicuous as possible. In such a contracted 
cavity, the object being to economize room, without com- 
promiting the interests of the offspring, we can think of 
no device better than that of a placenta. 

But notwithstanding the placenta offers a structure 



THE APPURTENANCES OF THE FETUS. 47 



apparently adapted to aerate tlie blood of the fetus, and 
no other reason can be assigned why so considerable a 
portion of its blood is sent thither, except that it may 
undergo this indispensable renovation, it may be asked, 
is there any positive proof that such a function is per- 
formed by the placenta? Such a question is the more 
likely to be put, since so eminent a teacher as Dr. 
Blundell expresses doubt upon the subject. He has, as 
he informs us, been at some pains to get blood from the 
umbilical arteries and vein at the same time, and has not 
observed any difference between them, in point of color, 
or, if any, only a mere shade. But Dr. Blundell did 
not make proper allowance for the peculiar economy of 
the fetus, if he expected to observe as marked a differ- 
ence of color between the arterial and venous blood of 
the cord, as between that of the pulmonary artery and 
veins. For it should be remembered that the blood of 
the mother is not, and cannot be safely, as highly char- 
ged with oxygen as atmospheric air ; and could it be, 
there is reason to believe, that it would prove destruc- 
tive to the tender organization of the fetus, its delicate 
tissues not being able to bear the infusion of highly oxy- 
dized and proportionably stimulating blood. There is 
yet another circumstance which, if duly considered, would 
not have allowed Dr. Blundell to look for a scarlet 
current in the vein and purple currents in the arteries 
of the cord ; namely, the blood that flows to the placenta 
through the umbilical arteries is not, strictly speaking, 
venous in its qualities, but it is just such blood as is dis- 
tributed to every part of the fetal system, for its nour- 
ishment and growth. It is a mixture of arterial and 
venous blood, detached from the circulatory torrent, and 



48 RUDIMENTS OF PARTURITION, 



sent forth to the placenta for a small additional dose of 
oxygen, and to part with a httle carbon. The blood in 
the two sets of vessels ought not, therefore, to be ex- 
pected to differ more than a shade in color. 

The observations of Dr. Bhmdell, if they were 
carefully made, go far to corroborate the old English 
doctrine in relation to a cardinal point in the physiology 
of the fetal circulation, which, nevertheless, I consider 
firmly established by other facts and reasoning. The 
cardinal point referred to is, the necessary admixture of 
arterial blood from the placenta, and venous blood from 
the head and superior extremities, in the cavities of the 
heart of the fetus, and the equal distribution from thence 
to all parts of its body of this mixed blood. In oppo- 
sition to this, it is well known, the French school of 
anatomy and physiology maintains that the arterial and 
venous currents, in their transit through the cardiac 
cavities, are kept, in a great measure, separate ; arterial 
blood being distributed to the head and upper extremi- 
ties, and venous blood to the nether parts of its body, 
as being good enough for them. 

A full discussion of tliis controverted point would 
be irrelevant to our present subject ; but I may be per- 
mitted to remark, that if the doctrine of the French 
school were true, the blood of the umbilical arteries 
would be found to differ more than a shade from that of 
the umbilical vein, although, for a reason already given, 
there would not be the striking contrast that is observed 
between the blood of the pulmonary artery and that of 
the pulmonary veins in a breathing animal. 

If, however, not even a shade of difference in color 
could be detected in the blood of the umbilical vessels, 



THE APPURTENANCES OF THE FETUS. 49 



the fact might be explained by the imperfection of the 
placental functions which must exist whenever it is 
possible to make observations of this kind. The child 
is expelled, and the womb is, of course, very considera- 
bly reduced in volume ; the placenta may be actually 
detached, though still in the uterine cavity. If the pla- 
centa be detached, although the umbilical vessels may 
continue, for a time, to carry on their accustomed circu- 
lation, there can be no aeration of the fetal blood in the 
placenta, nor is it needed, the lungs having come into 
play. If the placenta be adherent, the diminished cali- 
ber of the uterine arteries and veins, resulting from 
the reduced size of the womb, must render placental 
respu^ation less perfect than before the birth of the 
chHd. 

We have abundant proof that the fetal blood is 
aerated in the placenta, in the consequences that arise 
from compression of the cord to such a degree as to ar- 
rest the circulation of the blood in its vessels. Such 
compression is hable to happen, during labor, when the 
cord prolapses before the head of the child, in vertex 
presentations, and also while the head is passing through 
the pelvis, in nates presentations; and whenever it does, 
death is the consequence, while both the celerity and 
manner of death show clearly that it is caused by suffo- 
cation. The cord ceases to pulsate, and the fetus, after 
a short convulsive struggle, evinces no further indica- 
tions of life. 

Secondly ; The placerda is the organ through which 
the fetus derives its noiiriskment from the mother. 

Of this, it must be confessed, there is no positive 
evidence; but, at the same time, it may be safelv 
4 



60 RUDIMENTS OF PARTURITION. 



affirmed that, in relation to this point, negative evidence 
is altogether satisfactory. There is absolutely no other 
medium through which the fetus can obtain its supplies 
of alimentary matters. The only other possible source 
is the liquor amnii, the fluid which surrounds the fetus; 
and the doctrine that this is appropriated, either by ab- 
sorption or deglutition, has long since been exploded, by 
facts and arguments that cannot he answered, which 
need not be rehearsed in this place. How or in what 
form nutriment is received through the placenta, is not 
known; most probably there is a set of vessels, in con- 
nection with the umbilical capillaries, which open into 
the maternal portion of the placenta, and, abstracting 
from thence the needful supplies, convey them at once 
into these capillaries, to be incorporated with the fetal 
blood. Whether these hypothetical vessels take up 
blood, or only certain of its elements, we do not know; 
nor, as far as I can see, is it a matter of the least prac- 
tical moment that we should know. Nature here, as 
elsewhere, is chary of her revelations that might gratify 
the curiosity, without adding to the resourccb of her 
votaries. 

(C. ) The umUlical cord. The umbilical cord is a 
vascular rope, of varying length and thickness, stretch- 
ing from the umbilicus or navel of the fetus to the pla- 
centa. It consists of bloodvessels, surrounded by more 
or less gelatinous substance, and enveloped by two 
membranes, which are reflected upon it from, the inter- 
nal surface of the placenta, being nothing more than 
continuations of the two fetal membranes proper, viz., 
the chorion and amnion. No nerves or absorbents be- 



THE APPURTENANCES OF THE FETUS. 51 



long to it, and hence it is devoid of sensibility, either in 
relation to the child or mother. 

The bloodvessels of the cord have been partially 
described already. The placenta is so essentially con- 
nected with them, and, indeed, constituted in such large 
part by them, that no account of it would be intelligible 
without some knowledge of them. The umbilical arte- 
ries, arising from the internal ihacs of the fetus, or be- 
ing rather the main trunks of these vessels, ascend into 
the cavity of the abdomen, conducted by the sides of 
the urinary bladder ( which is, inthe fetus, an abdomi- 
nal organ), and pass out at the umbilical opening. 
When they make their exit, they begin to wind around 
the umbilical vein, and run in a spiral manner to the 
placental termination of the cord, where they divide 
into several large branches, conspicuous upon the inter- 
nal surface of the placenta. These branches penetrate 
the placenta, and, dividing into smaller and smaller 
branches, end in the system of capillary vessels, belong- 
ing to the dendritic processes of the chorion. 

The umbilical vein, taking its origin from the capil- 
laries of its associate arteries, traverses the cord in the 
opposite direction, as a single large trunk, enters the 
abdomen of the fetus, at the umbilical aperture, ascends 
along the hnea alba to the under surface of the liver, 
when it assumes a horizontal dkection, to reach the in- 
ferior vena cava, sending in its course two large branches 
to the hver. Through it a part of the blood, renovated 
in the placenta, is conveyed directly to the heart, and 
the remainder is distributed minutely to the liver, to be 
still further depurated by its secretory action, — its su- 
perfluous carbon, with other elements, being converted 



52 RUDIMENTS OF PARTURITION. 



into bile. What a heterogeneous mixture takes place 
in the cardiac cavities of the fetus ! Here comes a 
stream of blood directly from the placenta, through the 
main channel of the umbilical vein, most uselessly call- 
ed the ductus venosus ! There comes a stream of black 
venous blood, from the inferior parts of the body of the 
fetus ! ! Here comes a stream of depurated blood from 
the liver ! ! ! And these three kinds of blood, poured 
into the heart by the inferior cava, meet and mingle 
with a stream of venous blood from the superior cava. 
They are all commingled in the heart, and sent forth in 
harmonious union to all parts of the body, except what 
is dispatched to the placenta as a purveyor of oxygen 
for the corporation, — not that itself needs oxygen more 
than the blood it leaves circulating in the fetal vessels. 
But it is time to arouse from this pleasing, physiologi- 
cal revery, and resume our plodding way. 

Of the two membranous coverings of the cord, the 
outermost is the amnion, and in tracing them toward 
the fetus, they are found to terminate abruptly within 
half an inch or so of its abdomen, — the line where they 
end, and the skin or common integument of the fetus 
begins, being indicate by a marked difference of color. 
There is no reason, I judge, to believe that one of these 
tissues is transformed into the other, as some have 
imagined, and it is always at the Hue of demarcation 
between them that the cord separates and becomes de- 
tached, in a few days after the birth of the child. 

The umbilical cord exhibits, even to a superficial 
observer, several nodosities, which appear like varicose 
dilatations of its vein ; but these will be found, on dis- 
section, to be owing to that vessel doubhng upon it- 



THE APPURTENANCES OF THE FETUS. 53 



self, that is, at sucli points, the vein turns back a short 
distance and then proceeds foiTrard, — a contrivance 
which may possibly be a substitute for valves, of which 
it is entirely destitute. But besides these nodes, the 
cord sometimes presents a veritable knot, single or dou- 
ble, and occasionally even triple, an mstance of which 
last occurred to the celebrated Baudelocque, and was 
deemed by him so curious that he gives a figure of it, 
in a plate ( No. VII), devoted to this knotty subject. 
In that instance the cord was unusually lengthy, the 
triple knot was about a foot from the umbihcus, being 
as tightly drawn as is possible in such a case, and the 
cord, thu'ty-six or seven mches in length, was besides 
coiled twice about the neck. The circumstance last 
mentioned, viz., the cord encu'cling the neck, — an ex- 
ceedingly common thing whenever it is longer than 
usual, — affords the key to an explanation of these 
knots, at least when they are single. They are tied by 
the fetus slipping through the circle about its neck; 
but I must confess, with Baudelocque, that it is difficult 
to account for such a triple knot, as he has figured, not 
being able to perceive clearly how the fetus could have 
tied it with its neck. 

It was, at one time, a topic of disputation, whether 
these knots could be so tightly drawn as to destroy the 
fetus. It is difficult to beheve in the possibihty of such 
a catastrophe, seeing that the knot can only be tight- 
ened by such tension of the cord as would probabl}' 
tear off the placenta from the uterus. Dr. Smellie 
assigns this, nevertheless, as one cause of the death of 
the fetus in utero, and in one of his Collections (XZX 
JVo. 2, Case I), relates a case occurring in hisownprac- 



54 RUDIMENTS OF PARTURITION. 



tice, in which, when he Avas first called, the membranes 
had raptured, brownish and offensive waters were esca- 
ping; and the child, when expelled, was of a livid hue, 
its abdomen tumid, the epidermis easily peeling off, and 
the cord, about ten hands breadth long, was swollen and 
livid, having a tighthj-draivn knot on its middle. The 
knot and death may, however, have been only coinci- 
dences. 

In asserting, at the opening of this chapter, that 
the fetus is indebted to the mother for more than 
lodging merely, it was not meant to disparage comfort- 
able accommodations in this respect, for the provision 
made for it, albeit unwittingly as far as the mother is 
concerned, is admirable, and points to a higher and 
tenderer hand that spreads its bed and protects it 
from harm. The provision, alluded to, is found in 
the liquor amnii, the tvaters^ as they are sometimes 
called, which requires a brief notice, before we dismiss 
the present subject. This is usually a limpid, though 
sometimes turbid, fluid, consisting of serum, holding a 
small quantity of salts in solution, which surrounds the 
fetus and fills the sack of the amnion. It serves to 
protect the fetus from external injuries, and at the 
same time secures a certain space for its gambols. It 
is, moreover, the mother's defense against the pain 
which she would otherwise experience from the move- 
ments of the fetus, and, when labor sets in, it expedites 
the process by which the fetus is ushered into the 
world. 



THE UTERUS AS AN ORGAN OF EXPULSION. 55 



CHAPTER ly. 

THE UTERUS, — COXSIDEEED AS AN ORGAN DES- 
TINED TO EXPEL THE FETUS. 

The texture of the uterus is not homogeneous, but 
consists of several of the anatomical elements or tissues, 
which compose the various organs of the body. It pos- 
sesses a serous, cellular, muscular, and mucous, or sero- 
mucous coat, and is abundantly supphed with nerves, 
both sympathetic and cerebro-spinal, with bloodvessels 
and lymphatics. In reference to its parturient function, 
one of the most interesting of these tissues is the mus- 
cular ; — the disposition of whose fibers merits the special 
study of the obstetrician. A suitable knowledge of the 
size, form, divisions, and relations of the uterus being in- 
dispensable to the study of its structure, I shall first 
offer a brief description of it, as observed in a state of 
vacuity. 

The uterus is of a pyriform shape, flattened upon its 
anterior and posterior surfaces, and is contained entkely 
in the peMc excaA'ation, being situated between the 
bladder and rectum. Its base or largest part looks up- 
ward and forward, and is not above the level of the su- 
perior strait ; its apex looks downward and backward to- 
ward the inferior extremity of the sacrum. The axis, or 
length of the uterus, then, corresponds with the axis of the 
superior strait. The base of the uterus, smoothly covered 
mth peritoneum, reflected fi:om the bladder, is loose or float- 



66 RUDIMENTS OF PARTURITION. 



ing, and is brought into relation with the abdominal vis- 
cera; while its apex is contained within the vagina, — 
this canal, extending from the vulva in the direction of 
the axis of the inferior strait, and embracing the uterus, 
to which it is firmly united about half an inch above its 
apex. 

Being flattened upon its anterior and posterior sur- 
faces, the uterus has three borders or edges, — one, su- 
perior, which is convex, and two lateral, which are slight- 
ly concave. Its lateral borders being concave, at the 
points corresponding to the greatest depth of the con- 
cavities, the uterus is narrower across than either above 
or below. Three angles are formed by the meeting of 
these borders, — two superiorly, where the fallopian tubes 
enter the uterus, and just below which the round liga- 
ments take their origin, and one inferiorly, at the apex- 
The peritoneal covering of the anterior and posterior sur- 
faces of the uterus, reflected fi:*om the lateral borders to 
the sides of the pelvis, constitutes the broad ligaments, 
and incloses the round ligaments, tubes, and ovaria. 

Since the time of Levi^et and Eoederer, it has been 
usual to divide the uterus into the fundus, hodij, and 
cervix. Suppose a section of the organ made across its 
greatest width, that is, from the entrance of one faflopian 
tube to that of the other, the solid above this section is 
the fundus; make another section across the narrows 
(akeady described), and the solid, intercepted between 
this and the first section, is the body; what remains be- 
neath the second section is the cervix. (1) 

(1) Maxima uteri latitudo est inter tubarum fallopianarum inser- 
tiones. Fingatur ibidem transversim sectus, solidum enatura supra 
banc sectionem Uteri Fundus vccatur. Ab bac secticne imagiLaria 



THE UTERUS AS AN ORGAN OF EXPULSION. 57 



I prefer, however, the division which nature has 
clearly indicated, into lody and neck^ — the bodj^^ being 
above, and the neck below, the narrows. The fundus is 
entirely an arbitrary di^dsion; it makes, as we shall see, 
no part of the cavity of the uterus, being merely, as in- 
deed the term imports, the lottom of the ca^dty, and is 
consequently no more entitled to be reckoned a division 
than the sides of the cavity. I shall continue to em- 
ploy the term, fundus, but always in the sense now ex- 
plained. 

If we cut into the uterus, from its fundus to the 
apex, a cavity is brought to view, whose shape corres- 
ponds to the external configuration of the organ: it is 
plainly divided into two portions, one belonging to the 
body and the other to the neck. The cavity of the lody 
is of a triangular figure, and has an orifice at each of its 
angles: 1. one inferiorly, which communicates with the 
cavity of the neck, and is called the os internum^ or cer- 
vico-uterine orifice] 2. two superiorly and laterally, which 
are the minute orifices of the fallopian tubes. The fun- 
dus not only does not make any part of this cavity, as 
has been already observed, but in the virgin uterus i^ 
even encroaches upon it, — its internal surface being con^ 
vex, as well as its external, so that it somewhat resembWs 
the bottom of certain bottles. But in the gravid state 
of the organ, it is prodigiously expanded, and made to 
bulge outwardly, so as to contribute most largely to the 



ad sectionem alteram imagiuariam, quse concipitur trausversa iu loco, 
ubi mimma uteri latitudo, interceptum solidum Uteri Corpus consti- 
tuit. Reliquum, quod infra banc sectionem superest, Cervix 2.yx^\i. 
{Rcederer — Element., Art. Obstet., s. 34.) 



58 RUDIMENTS OF PARTURITION. 



augmentation of its cavity. The same is true likewise 
of the sides of this cavity. 

The cavity of the neck is narrower than that of the 
body, and is fusiform, or spindle-shaped; that is, it is larger 
above than below, and is somewhat bulging in the mid- 
dle. It communicates with the vagina by an orifice in 
the form of a transverse slit, with an anterior and pos- 
terior lip, which is called the os externum^ or vaginal ori- 
fice. That part of the neck which projects into the va- 
gina (the apex of the uterus), upon whose summit this 
external orifice is found, is the os tinccBy or os uteri. 

Having premised this short description of the uterus, 
which seemed essential to our purpose, I proceed to no- 
tice its muscular structure, to which, as I have said, it is 
largely indebted for its properties as an expulsive organ. 
It is not now, as it once was, necessary to enter into an 
argument to prove the genuine muscularity of the uterus, 
for this is, at the present time, generally admitted. In 
the vacant state of the organ, it must be confessed, this 
structure is so little apparent, and the fibers belonging 
to it are so destitute of anything like methodical arrange- 
ment, that it is no wonder many authors refused to give 
it a more distinctive appellation i]mxi fibrous coat, or even 
tunica propria, which signifies nothing as regards its 
nature. In the quiescent state of the organ, there is no 
use for a well-ordered muscular coat, and hence nature, 
always economical in her endowments, allows it to remain 
in a rudimentary condition. The fibers are all there, 
but they are but little developed, and instead of obser- 
ving any definite distribution, they cross each other at 
all angles, and form an inextricable tangle. But when 
touched by the magic wand of generation, these fibers 



THE UTERUS AS AN ORGAN OF EXPULSION. 59 



begin to appear in their true character, and to arrange 
themselves in the most advantageous order, and by the 
close of gestation, they are ready to fulfill what is required 
of them. 

The foregoing remarks are strictly true of the fibers 
belonging to the lody of the uterus (to which, as we 
shall see, the expulsive trust is confided), but only par- 
tially true of those of the nedi. Upon laying open the 
cavity of the neck, especially of the virgin uterus, a 
longitudinal column of fibers will be observed upon the 
mesial fine of its anterior and posterior walls, and two 
others, not so prominent as these, at the sides of the ca- 
vity. From the mesial columns little fasciculi of fibers 
proceed upward and outwardly, on both sides, in a pen- 
niform manner, to meet and unite on the lateral columns. 

This pecuhar arrangement of its fibers gives to the 
interior of the cervix uteri an arborescent appearance, 
which has been called the arlor vitce, whether from a 
fancied resemblance to the shrub so named, or because 
under its branches hes the pathway to life, I know not. 

The arrangement of the muscular fibers of the ute- 
rus, particularly of its body, even at the term of gesta- 
tion, is not a little intricate and complex; it is no won- 
der, therefore, that Baudelocque and most of the French 
obstetricians abandoned all hope, as M. Velpeau says, 
(1) of being able to determine it, and adopted the idea 
of Miiller, that these fibers are all disposed in loops 
parallel to the axis of the uterus, or in horizontal cir- 
cles, — the first chiefly forming the body and fundus of 



(1) Traite Complet de 1' Ai't des Accouchemens ; deuxieme ed. 
Paris, 1835. Tome 1, p. 86. 



GO RUDIMENTS OF PARTURITION. 



the uterus, while the second ai^e found more especially 
in the neck. Dr. Dewees, I know not by what au- 
thority, invests the uterus with a complete suit of cir- 
cular as well as longitudinal fibers, extending from the 
OS uteri to the fundus, and was, for his pains, exceed- 
ingly puzzled to make the creature of his fanc}^ behave 
itself seemly during labor. 

We are indebted to the researches of Sir Charles 
Bell (1) and Madame Boivin (2) for more satisfactory 
views of the subject ; Vv^e may, indeed, flatter ourselves 
that it is now sufficiently well understood for all useful 
purposes. From these researches it appears — 

First. When the peritoneal covering of the uterus 
is removed, an external muscular layer is discovered 
upon the superior part of the body of the uterus, con- 
sisting of fibers that part from each other on the mesial 
fine of its anterior and posterior surfaces, and run ob- 
liquely downward and outward, to the borders of the 
uterus. The fibers from the fundus are continued upon 
the fallopian tubes and Hgaments of the ovaries, while 
the rest, from both surfaces of the uterus, converge to- 
ward and are continued upon the round ligaments 
which they, in fact, constitute. Madame Boivin, tracing 
these fibers from the mesial line, very aptly compares 
their appearance to that of the long hair of the human 
head, parted the whole length of the mesial fine of the 
cranium, smoothly combed on both sides of the forehead, 
and tied a little anterior to each ear. Sir Charles Bell, 

(1) Paper on "The Muscularity of tlie Uterus." — Med. Chi- 
riirg. Transact., Vol. lY, p. 338. 

(2) Traite Pratique des Maladies de 1' Uterus, par Mme. Boi- 
vin et A. Duges, Paris, 1833. Tom. II, et Atlas. 



THE UTERUS AS AN ORGAN OF EXPULSION. 61 



on the contrary, describes them as arising from the 
round ligaments, and spreading in a diverging manuer 
over the fundus until they unite and form the outermost 
stratum of the muscular substance of the womb ; the 
round hgaments he regards as theii^ tendons. His view of 
them is, I think, the most correct; but we may call them, 
with ]Madame Boivin, the ohlique fibers of the uterus. 
When it is remembered how largely the fundus of the 
uterus is developed during pregnancy, and that the 
whole of its expanded surface, even down to the inser- 
tion of the round hgaments, is invested with these fibers, 
we may form some idea of their extent. 

Secondly. Upon inverting the uterus and brushing 
off any portions of decidua that may be adhering, an 
internal layer of fibers will be easily seen, consisting of 
concentric circles around the orifices of the fallopian 
tubes. These cu'cles are, of course, small next to the 
orifices of the tubes, but enlarge as they recede, until 
the outermost ones meet and mingle upon the mesial 
line of the anterior and posterior surfaces of the uterus. 
These concentric fibers are described in the same man- 
ner by Sk Charles, and ^ladame Boivin, and any one 
may easily satisfy himself, as I have several times, of 
thek trustiness, by simply opening and looking into a 
recently gra^ad uterus. 

With regard to the fibers belonging to the inferior 
part of the body of the uterus, viz., the part below the 
insertion of the round ligaments ( which is compara- 
tively small, owing to the predominant development of 
the superior part ), nothing very definite can be said; 
they preserve much of the intricate interweaving that 
characterized them anterior to pregnancy, and somewhat 



G2 RUDIMENTS OF PARTURITION. 



of the same may be observed still in the superior por- 
tion of the organ, intermingled with the regular order 
just described. 

Thirdly, As to the fibers of the neck, Madame 
Boivin describes them as circular, with some remains of 
the arborescent appearance peculiar to them in the va- 
cant state of the uterus. Sir Charles Bell informs us 
that he " has not succeeded in discovering circular fibers 
in the os tincse, corresponding in place and oliice with 
the sphincter of other hollow viscera," but he does not 
tell us what he has discovered. I will endeavor to sup- 
ply the omission. If we lay open the cavity of the 
uterus of a woman who has died during parturition, or 
at an advanced period of pregnancy, when the neck is 
unfolded, and look toward the os tincse, we shall see 
that its external orifice is surrounded by a series of cir- 
cles, enlarging as they recede from the orifice. Each 
circle belonging to this set is composed of four segments, 
united upon the mesial line anteriorly and posteriorly, 
and at the sides of the neck, and we have no difficulty 
in recognizing these circular fibers as the penniform 
fibres, rendered horizontal by the expansion of the neck, 
which their peculiar arrangement is apparently adapted 
to favor. Such is the disposition of the fibers of the 
neck, as it appeared to me in the examination of seve- 
ral gravid uteri, even without the aid of dissection, 
and as one preparation in my collection will serve to 

show. 

The natural division of the uterus into body and 
neck has been already mentioned; we have noticed 
likewise a very remarkable difference between these 
parts of the same organ, in regard to the arrangement 



THE UTERUS AS AN ORGAN OF EXPULSION. 63 



of the muscular fibers belonging to them, in the unim- 
pregnated state, ^dz., penniform fibres in the neck, — 
an undefinable web in the body. Let us inquke 
whether there are any other points of anatomical dif- 
ference. 

From the most accurate investigations that have 
been made, it appears that they differ as to the tissue 
of then' fining membrane. A mucous membrane has 
been ascribed to the uterus, by most authors, as the 
lining of its entke cavity; but M. Moreau observes (1) 
that it is not possible to demonstrate the existence of 
such a membrane in the cavity of the lodij, by any of 
the processes resorted to by anatomists for such a pur- 
pose. Mucous membrane can be traced fi^om the vagina 
within the os tincse, but does not extend beyond the 
cavity of the cervix : here also there are imbedded in 
it a great number of mucous folficles, some of which are 
so large that they were mistaken for germs, by Naboth, 
and are hence called ova Ndbothi, These folficles occu- 
py the sulci between the penniform fibers ; whereas the 
surface of the cavity of the body is smooth, being alike 
destitute of rugae and muciparous foUicles, and is cor- 
rectly described by Moreau as soft and pulpy, of a 
brownish or dark-red color, and usually containing a 
brown or dirty-gray fluid. The anatomical evidence 
against the existence of mucous membrane in the cavity 
of the body is corroborated by a number of facts, one 
of which only I shafi. refer to : it is the complete obfit- 
eration of the cavity, frequently observed in old women 
as the natural consequence of its disuse, which has not 

(1) Traite Pratique des Accoucliemens; Tom. 1, p. 124. 



64 RUDIMENTS OF PARTURITION. 



been known to extend lower than the cervico-uterine 
orifice. Now, the cavity of organs furnished with true 
mucous membrane is not liable to be obliterated by 
such cause ; in cases of artificial anus, for example, 
the portion of intestine below the accidental opening 
continues pervious for life, although it no longer gives 
passage to fecal matter. 

The membrane lining the cavity of the corpus uteri 
is exceedingly delicate, — so delicate, indeed, that its 
existence has been called in question by Madame Boivin 
and Duges (1), and M. Moreau is perplexed to deter- 
mine its anatomical character. The latter remarks that 
the internal surface of this portion of the uterus has 
neither the brilliancy of the peritoneum nor the white- 
ness of the vaginal mucous membrane, and he regards 
it as 2i persinratorij surface^ intermediate, in respect to 
its organization and uses, between the serous and mu- 
cous tissues. 

These anatomical differences awaken a suspicion 
that the body and neck of the uterus are destined to 
perform different offices, and as the doctrine that 
they do perform different and antagonistic parts in the 
drama of labor will be maintained in the next chapter, 
we shall inquire now what evidence there is of this 
diversity of office under other circumstances than par- 
turition. 

First The body and cervix do not concur in the 
production of the menstrual discharge, which is exhaled 
entirely from the lining membrane of the body. This 
statement rests on the observations of Madame Boi- 

(1) See joint work, already quoted. 



THE UTERUS AS AN ORGAN OF EXPULSION. 65 



vin (1) who says expressly that she has often had oc- 
casion to examine the uterus of young girls, who died 
at the menstrual period, and has found the internal sur- 
face of the organ covered with a layer of bright-red 
blood ; that compression causes it to escape in numer- 
ous little drops from the body, but never from the neck, 
of the uterus ; and that it is now satisfactorily demon- 
strated that, in health at least, the menstrual discharge 
has its seat in the cavity of the body alone. Baude- 
locque (2) asserts, however, that the menses distil from 
small orifices which may be observed over the whole 
extent of the cavity of the uterus, including its neck 
and perhaps the vagina, and other writers concur in this 
view. The observations of Madame Boivin, therefore, 
need confirmation; but in the [meanwhile we have but 
little doubt of their correctness, and beheve that they 
furnish a strong argument in favor of the separate func- 
tions of the body and neck of the uterus. If the organ 
were a unit, in such a sense as to forbid its division 
into parts, anatomical or physiological, ought not the 
menses to flow equally from every portion of its inter- 
nal surface ? 

Secondly. The body and ne^k perform different 
offices during gestation. To the body it belongs to 
make preparation for the reception, growth, and accom- 
modation of the ovum ; to the neck, to make provision 
for its retention and safe keeping. Let us examine, in 
detail, these several offices of the body and neck, in or- 



(1) Memorial de 1' Art des Accouchemens, quatrieme edit. 
Paris, 1836, p. 62. 

(2) L' Art, &c. Tome I, p. 176. 

6 



66 RUDIMENTS OF PARTURITION. 



der to exhibit the isolated parts they play during preg- 
nancy. 

The preparation made for the reception of the ovum 
consists in the formation of a membrane that lines the 
uterine cavity and becomes the outermost covering of 
the fetus. Many discrepancies are to be found among 
authors concerning this deciduous membrane, but thus 
far all are agreed at present, viz., that it does not ex- 
tend into the neck, but lines only the cavity of the 
body. Dr. W. Hunter, it is true, describes and fig- 
ures it as continued down the passage in the neck of 
the womb and insensibly lost or blended with the gluti- 
nous cement (1). But later observers, who have inves- 
tigated the matter on a large scale, aver that the de- 
cidua does not pass the cervico-uterine orifice, but is 
stretched across it and also over the orifices of the fallo- 
pian tubes, and that thus it forms a perfect sack without 
any openings, filled with a fluid, limpid at first, but af-, 
terward slightly lactescent. According to M. Breschet 
(2), the decidua or the perione (as he calls it, from its 
surrounding the ovum ) extends several lines, some- 
times half an inch, into the fallopian tubes, appearing 
like appendices when»the membrane is removed entire 
from the cavity of the uterus. These appendices, more 
evident at an early period of pregnancy, are solid, and 
do not, therefore, extend or prolong the cavity of the 
uterus, and they serve, as M. Breschet conjectures, to 
fix the decidua, whose feeble adhesion renders it easily 

(1) Anatomy of the Gravid Uterus, London, 1815. 

(2) " Etudes de 1' OEuf." — Memoires de V Academie Rayale de 
Medicine, Tome. II, p. 1. 



II 



THE UTERUS AS AN ORGAN OF EXPULSION. 67 



liable to separation and displacement. M. Breschet 
agrees with Yelpeau and others, in declaring that the 
decidiia does not dip into the cervix uteri, which he 
thinks very singular, considering that it might have 
been prolonged in that direction more readily than into 
the fallopian tubes. But we cease to wonder at this, 
when we reflect that the body and cervix are distinct 
parts of the uterus, and have separate offices assigned 
them. 

The utility of the decidua in fitting the womb for 
the reception of the ovum is manifest: entangled in its 
pulpy substance, the minute and delicate ovum is pre- 
vented from dropping into the common cavity of the 
uterus, and is held steadily in apposition with the 
fundus or upper part of the organ until its connection 
is formed. If there were no decidua, the ovum would 
fall into the general cavity of the womb, and might as 
readily unite itself to the cervix as to the fundus — a 
location fraught with disasters and death, as we are 
taught by the melancholy cases of placenta prsevia that 
occasionally occur in practice. 

The provision made by the body of the uterus for 
the growth of the ovum is found first in this same decid- 
uous membrane, and subsequently in the maternal por- 
tion of the placenta, which is composed in part of the 
decidua. The fluid which is secreted into the decidual 
sack, the hydro- jjerione of M. Breschet, is the first 
nourishment that the uterus prepares for the ovum, and 
this is probably appropriated by imbibition. When its 
attachment is effected by the formation of the placenta, 
the hydroperione ceases to be secreted, and the umbili- 



68 RUDIMENTS OF PARTURITION. 



cal vein of the fetus takes up nourishment from the cells 
of the placenta by means of its numerous radicles. 
From this statement it is evident that the nourish- 
ment of the fetus is committed to the body of the 
uterus and not to its neck. 

The growing ovum requires for its accommodation 
the gradual enlargement of the cavity of the uterus. 
Does the cavity of the body or neck, or of both, en- 
large to furnish this accommodation? Baudelocque 
taught that both contribute, in a certain estabUshed or- 
der, that is, that during the first six months of preg- 
nancy, the body only of the uterus enlarges, on account 
of its fibers being more supple than those of the neck ; 
that at the sixth month the neck begins to be devel- 
oped to furnish its quota toward augmenting the cavity 
occupied by the fetus ; that henceforth the fibers of ev- 
ery part of the uterus are equally developed until near 
the close of gestation, when those of the body, having 
been developed first, offer the greatest resistance to fur- 
ther distention, and then there is no longer an equili- 
brium between them and those of the neck ; that, the 
equihbrium being broken, the fibers of the body begin 
to make efforts to expel the fetus, discoverable by the 
alternate relaxation and tension of the membranes, felt 
by the finger at the uterine orifice ; and that hencefor- 
ward the fibers of the neck, receiving the whole of the 
distending force of the uterine contents as well as the re- 
action of the body, are much more rapidly developed, 
and all further increase of the uterine cavity is obtained 
by their distention, which is so great that at the com- 
mencement of labor, the parietes of the neck are not 



THE UTERUS AS AN ORGAN OF EXPULSION. 69 



thicker than two or three sheets of ordinary paper (1). 
It will be perceived that this account of the develop- 
ment of the gravid uterus is based upon Levret's doc- 
trine of the antagonism of the body and neck. The 
antagonists, in the hands of Baudelocque, are made to 
operate in such a way as to explain the phenomena, as 
they were behoved by him to exist. Fnst the neck 
predominates, then there is an equilibrium between it 
and the body, and ultimately the body becomes pre- 
dominant and continues so until the induction of labor. 
Divested of speculation, the account is simply this : 
during the first six months, the distention is confined 
to the body, but fi:om this period the neck gradually 
shortens, its upper part being imperceptibly added to 
the cavity of the body until the end of gestation, when 
it forms together with the body one common cavity, 
and nothing remains of it but the cushiony ckcle of the 
external or vaginal orifice. 

This view of uterine development has been generally 
adopted by writers, who differ only as to the period of 
pregnancy when the expansion of the neck commences 
and is completed. But lately its truth has been ques- 
tioned, and now there is scarcely a doubt but it is en- 
tirely erroneous. According to the observations of M. 
Cazeaux (2), the neck, especially in women who have 
borne cliildren, preserves the whole of its length until 
the last fifteen days of pregnancy, or at least until the 
commencement of the ninth month. He avers that he 

(1) L'Art des Accoucliemens, Septieme edit. Paris, 1833, 
Tom. 1, p. 110. 

(2) Traite Theorique et Pratique de I'Art des Accouchemens. 
Paris, 1841, p. 59. 



70 RUDIMENTS OF PARTURITION. 



has repeatedly verified this fact, which had akeady been 
noted by Professor Stolz, of Strasburg, and pubhcly 
taught by Professor Dubois since 1839. "At this 
time " (November, 1839), says M. Cazeaux, "I have in 
my course a woman advanced to the last fifteen days 
of her pregnancy, in whom the internal orifice is not 
yet opened, though the neck below it is sufficiently 
dilated to admit the whole of the first, and half of the 
second, phalanx of the finger." It thus appears that, in 
women, who have borne children before, the expansion 
of the neck commences below, and extends upward^ 
reaching its middle by the seventh month, and nearly 
to the internal orifice toward the end of the ninth, 
when the cavity of the neck resembles an inverted fun- 
nel. At this time, the internal orifice is puckered and 
closed like a purse; but it finally dilates, and permits 
the finger to reach the membranes, after passing 
through a cyhndrical canal, an inch to an inch and a 
half long. The membranes can sometimes be touched 
as early as the seventh month, by passing the finger 
through this cervical canal. 

In primiparse, the cervix uteri offers some pecufi- 
arities, which, as far as our present subject is concerned, 
consist in its shortening somewhat, instead of preserv- 
ing, its usual length, throughout the greater part of 
pregnancy, as in multiparse, and in its expansions com- 
mencing, according to M. Cazeaux, above, and extend- 
ing downward. Professor Stolz (1) explains this 
shortening in the following manner: At the sixth 
month, the vaginal portion of the neck begins to shorten, 

(1) Quoted by M. Cazeaux, Op. Cit. 



THE UTERUS AS AN ORGAN OF EXPULSION. 71 



while it ividens at its superior fart. The external 
orifice, continuing closed, approaches the internal, and 
consequently the cavity of the neck becomes larger in 
the middle, until the tivo orifices are Irought near each 
other ; the internal orifice then opens fitrst^ which hap- 
pens during the last fifteen days of pregnane}^; the rest 
of the 1)0 dy disappears much more rapidl^^ than it had 
done before, and a projection can no longer be felt; the 
external orifice remains closed. 

M. Cazeaux, while he will not reject the explanation 
of M. Stolz, acknowledges that he cannot reconcile 
these two phrases, which he underlines — tlie sii/perior 
part of the neck expands, then the internal orifice opens 
first. If the superior part of the neck widens at the 
sixth month, he inqukes, how can the internal orifice 
still exist at the end of pregnancy? This would truly 
offer an insurmountable difficulty; but Professor Stolz, 
as quoted by M. Cazeaux himself, does not say that the 
superior part of the neck, but of its vaginal portion, 
widens at the sixth month; and in saying that, some 
time after this occurs, the internal orifice opens, there is 
nothing that needs to be reconciled. 

The observations of Professor Stolz are substantially 
confirmed by M. Chailly; and the entire account, which 
he gives of the changes that the neck undergoes during 
pregnancy, contradicts the hitherto received opinions of 
writers on the subject. 

There is one weU-known fact, to which we may al- 
lude, that goes far to establish the accuracy of these re- 
searches of MM. Stolz, Dubois, Cazeaux, and Chailly, 
if it be not of itself sufficient to refute the opinion for- 
merly entertained. It is this : When the neck of the 



RUDIMENTS OF PARTURITION. 



uterus is so much developed as to allow the finger to be 
passed to its upper orifice, which it is by the seventh 
month in multiparse, the membranes can be felt and are 
organically united to the uterus around the margin of 
the orifice. When, again, the neck is entirely obliterated, 
as it is at term, the membranes can be felt and are still 
attached around the os uteri. Now, as it is admitted 
that during the first five or six months, the ovum is 
confined to the cavity of the body, and that the neck is 
not lined with decidua, were the obliteration of the 
neck owing to the expansion of its upper part, either 
the membranes would be too high to be reached by 
the finger; or if they were sufficiently extensible to 
be pushed down into the expanding neck by the grow- 
ing ovum, they would not be found adhering to its 
surface. The latter declaration is authorized by the 
fact that, in the progress of gestation, the membranes 
become less vascular, and the disposition of the internal 
surface of the uterus to throw^ out organizable lymph 
no longer exists. But in either case, at the seventh or 
ninth month, the membranes are found to have vascular 
connection around the uterine orifice, for when separated 
by the finger, or by the uterine contractions, as in the 
latter case they are, so soon as labor commences, there 
is a slight effusion of blood. 

We conclude, therefore, that the neck contributes 
nothing to the cavity of the gravid uterus, A^hich is 
made up entirely of the dilated cavity of the body, 
and consequently it has been shown that the body of 
the uterus fulfills the various ofiices imposed upon it by 
pregnancy. 

We have next to inquire how the cervix uteri ac- 



I 



THE UTERUS AS AN ORGAN OF EXPULSION. 



quits itself of the custody, wliich I have said is con- 
iided to it. In the first place, shortly after impregna- 
tion, the muciparous follicles pour out an abundant secre- 
tion of their peculiar viscid mucus, which concretes into 
a plug that stops up its cavity, as effectually as a cork 
does a bottle. Dr. Burns says that this plug may be 
extracted enth-e by maceration, when a mold of the la- 
cunae will be obtained by floating it in spirits saturated 
with fine sugar (1). It is necessary that the uterine 
cavity should be sealed in this manner, to prevent the 
escape of its contents, or the intromission of an}i3hing 
that might disturb its delicate arrangements. No 
stronger proof of the functional difference between the 
neck and body of the uterus can be required, than is 
afforded by the different products of their action, ex- 
cited by the same stimulus, that of impregnation. While 
the body secretes plastic lymph, that becomes organ- 
ized into a membrane having vascular connection with 
its internal surface, the neck secretes tough mucus that 
forms an inorganic cement, having no vital communica- 
tion with it. 

In the second place, the cervix uteri acts as a sentry 
over the product of conception, by not participating in 
the development of the body until gestation is conside- 
rably advanced, and then only in a gradual manner, and 
after a fashion pecuhar to itself Should it begin pre- 
cipitately to be developed, or progress too rapidly, it 
loses its ef&cacy as the antagonist of the body, and the 
premature expulsion of the ovum is the consequence. 

(1) Principles of Midwifery, with notes, by T. C. James, M. D. 
Amer. edit, from the 5th London edit., Yol. I, p. 170. 



74 RUDIMENTS OF PARTURITION. 



Baudelocque was fully persuaded that this is a frequent 
cause of abortion : he avers ( 1 ) that he has met with a 
number of cases wherein premature expulsion was at- 
tributable solely to the organic feebleness, natural or 
acquired, of the cervix uteri ; and in watching the de- 
velopment of this part, he has confidently predicted 
that miscarriage would take place at the fifth, sixth, or 
seventh month, according to the degree of development 
at the time of examining, and the event uniformly ver- 
ified the prediction. M. Gardier(2) confirms the 
truth of Baudelocque's statements: "There is no doubt," 
says he, "but premature labor is often the consequence 
of the slight resistance, natural or accidental, of the cer- 
vix uteri ; and by touching a woman we may, as I have 
often shown the pupils assisting my practical courses, 
predict that labor will come on at the sixth, seventh, or 
eighth month, forming our judgment upon the changes 
which the cervix has undergone in its length and den- 
sity." Levret had, indeed, made the same observation 
before Baudelocque or Gardier* for without the antago- 
nism of the cervix, he declares that the product of con- 
ception would entirely escape before term, and that, in 
the majority of cases, this accident is to be ascribed to 
default of this "mechanical action," as he terms it (3). 
If, then, the neck contributes nothing to the cavity 
destined to contain the fetus, nothing to the reception 
or maintenance of the ovum, but shuts up the cavity 

(1) L'Art des Accouchemens, Tom. I, p.' 113. 

(2) Traite Complet d' Accouchemens, Tom. I, p. 162. Troi- 
sieme edit., Paris, 1824. 

(3) L' Art des Accouchmens, demontre par des Principes de 
Physique et de Mechanique. Paris, 1766, p. 89. 



THE UTERUS AS AN ORGAN OF EXPULSION. 75 



and opposes the exit of the contents, it is truly the 
sphincter of the uterus, for such is the very definition 
of the term. What avails it to object with Sir Charles 
Bell (1) that there are no circular fibers in the os tincse 
corresponding in place and office with the sphincters of 
other hollow viscera/' or that the " loosening of the ori- 
fice, and softening and relaxation which precedes labor, 
is quite unhke the yielding of a muscular ring ?" Such 
a sphincter as that of the rectum or urinary bladder, 
would be altogether unfit for the uterus, which has 
to retain its contents nine months. The uterine 
sphincter ought to be constructed and endowed with 
reference to a more persistive exercise of its office, else 
premature expulsion of what it is appointed to keep 
must, as we have seen, be the consequence. A mere 
ring of muscular fibers, like that of the rectum or blad- 
der, would be inadequate to the retention of the con- 
tents of the gravid uterus for nine months. Again : the 
uterine sphincter must not yield to the expulsive efforts 
of labor, as readily as that of the rectum or bladder, in 
defecation or micturition, else the woman and her off- 
spring will be exposed to the dangers that are known 
to attend precipitate defivery. Hence the necessity of 
a sphincter that will offer considerable resistance to the 
escape of the child — precisely such a one as the uterus 
possesses (2). 



(1) Medico Chir. Transact. Vol. lY, p. 345. 

(2) " And even if experience (wliicli after all is of the most 
importance) did not distinctly show that easy and rapid labors are 
always dangerous, and seldom without injurious consequences, 
analogy on the one side, and a nearer consideration of this great 
phenomenon of nature on the other, would lead to the conclusion 



76 RUDIMENTS OF PARTURITION. 



The facts and observations which have now been ad- 
duced, are sufficient to prove the distinct and opposite 
offices of the body and neck of the uterus, or we know 
not how any truth in physiology can be proved. 

But the uterus, notwithstanding its natural division 
into body and neck, and its complete equipment of 
muscular fibers, would fail to fulfill its offices as an 
organ of expulsion, were it not suitably endowed with 
nerves, to put it in relation with other organs, and ena- 
ble it to receive and respond to impressions made upon 
it. It is accordingly supplied with nerves in great 
abundance, and from the two great centers of the ner- 
vous system, namely, from the great sympathetic and 
the cerebro-spinal axis. For a full description of the 
uterine nerves, the reader is referred to the works of 
Dr. Robert Lee, of London (1), who has labored more 
successfully, as it appears to me, in this branch of ob- 
stetrical anatomy, than any of his predecessors. I shall 
attempt nothing more than to give an abstract of his 
observations, and, in doing this, use, as much as possi- 
ble, his own language. 

The nerves that are sent immediately to the uterus 
from the great sympathetic are derived from the hypo- 
gastric plexuses, and a large, oblong ganglion upon either 

tbat a certain duration of time, certain difficulties, an effort of the 
strength, a struggle, &c., belong to the essential requisites of the 
safe, uninjurious, and, in short, health}^ progress of the function." — 
C. F. NcegeU, on the Mechanism of Parturition, translated from the 
German, by Dr. Righy, section 12. 

(1) The Anatomy of the Nerves of the Uterus, with two 
plates, London, MDCCCXLI; Lectures on the Theory and Prac- 
tice of Midwifery, delivered in the theater of St. George's Hospi- 
tal, Amer. edit., sect. 11. 



THE UTERUS AS AN ORGAN OF EXPULSION. 77 



side of the neck of the organ. The hypogastric plex- 
uses are situated upon the sides of the pelvis, behind 
the peritoneum, and in the yicinity of the bloodvessels 
of the same name, viz., the hypogastric arteries and 
veins. These plexuses are formed by the numer- 
ous branches of the right and left hypogastric nerves, 
which issue from a plexus higher up, namely, the aortk, 
formed by the two cords of the great sympathetic 
nerve, over the last lumbar vertebra, at the bifurcation 
of the aorta. The trunks of the hypogastric nerves 
proceed through their plexuses to the lower part of the 
uterus, where they terminate in the cervical gangha, 
already mentioned. Each of the hypogastric plexuses 
give off several branches to the ureter, rectum, and 
uterus; those sent to the uterus being of considerable 
size, and spreading themselves extensively under its 
peritoneal coat. The uterine arteries and veins receive 
large branches, ^^hich accompany them in their ascent 
along the sides of the organ, and, becoming thin and 
broad, terminate in great plexuses that completely en- 
cu'cle the vessels. These plexuses about the vessels are 
joined by several branches from the cervical gangha, and 
they send branches to accompany all the ramifications 
of the vessels, passing with them into the muscular 
coat of the uterus. 

The body of the uterus is encircled by a great trans- 
verse plexus of nerves, — regarded by Dr. Lee as the 
special nervous system of the uterus, — into which 
nerves, both from the hypogastric plexuses and the cer- 
\ical gangha, enter. This transverse plexus is described 
as arising near the mesial line on the posterior surface of 
the organ, from a mass of fibers which adheres so firmly 



78 RUDIMENTS OF PARTURITION. 



to the peritoneum as well as the muscular coat, that it 
is difficult precisely to determine their arrangement; 
and from thence the plexus proceeds across the uterus, 
in the form of a thin web, to unite with a plexus on 
the anterior surface of the organ, spreading out into a 
great web under the peritoneum. This great transverse 
plexus is loosely attached through its whole course to 
the subjacent muscular coat, by soft cellular tissue. 
From every part of it, branches of nerves are seen pass- 
ing between the fibers of the muscular coat, and, like 
nervous branches in other muscular organs, dividing into 
smaller branches as they enter. 

The spermatic nerves, from a higher source of the 
great sympathetic, attend the spermatic vessels in their 
course to the ovaria, and after supplying these organs 
with many branches, form anastomoses with branches 
of the hypogastric and uterine plexuses. 

Finally. From the second, third, and fourth sacral 
nerves, but chiefly from the third, branches pass into the 
posterior borders of the ganglia at the cervix, and are 
lost in their mass. These accessions to the ganglia are, 
of course, from the cerebro-spinal system of nerves; and 
now let Dr. Lee's account of the nerves proceeding 
from the ganglia, be particularly noted. From their in- 
ner surfaces, he says, numerous small, white, soft nerves 
are given off to the neck of the uterus, some of which 
ramify under the peritoneum, and others pass deep into 
the muscular coat. From their anterior and inferior 
borders, many large nerves are given off to the blad- 
der and vagina, and from their posterior margins to the 
rectum. 

The researches of Dr. Lee have completely settled 



THE UTERUS A3 AN ORGAN OF EXPULSION. 79 



the controverted question whether the nerves of the 
uterus are enlarged by pregnancy. The nerves were 
found to be larger in gravid than in unirapregnated 
uteri (much larger in the ninth month of pregnancy), 
and, as early as even the tenth day after delivery, in a 
woman who died suddenly, it was discovered that the 
h}T)Ogastric plexuses, and those both on the anterior 
and posterior smfaces of the body of the uterus, were 
very much reduced in size from what they are observed 
to be m the uteri of nine or even six months. '^ This 
observation made it certain," as he justly remarks, ^^that 
the nerves of the uterus, after having performed their 
proper function durmg gestation and in labor, gradually 
return to the condition in which they are found in the 
unimpregnated uterus." 



80 



LABOR, 



CHAPTER V. 



LABOR— ITS EFFICIENT CAUSE. 



For human parturition, the term "labor" is a very 
appropriate cognomen, because seldom does woman bring- 
forth except "in the sweat of her face;" and the most 
excruciating sufferings are fitly compared to the pangs 
of childbirth, because none can be imagined greater. 
The word, labor, whose original meaning is fatiguing or 
painful exertion of any kind, is, therefore, more signifi- 
cant than "parturition," which expresses the act, but 
none of the concomitants, of child bearing. I shall ac- 
cordingly employ the term, not, however, to the exclu- 
sion of that of "parturition," but convertibly. Labor 
was formerly regarded as the result of the active efforts 
of the fetus itself, instinctively exerted to procure its 
release from confinement. It is strange that such a 
crude notion received the sanction of even the illustrious 
Harvey, whose incidental allusions to it show plainly 
that he no more questioned its truth, than that of the 
discovery which has immortalized his name. In his 
description, for example, of the case of a lady, the 
mother of several children, who became pregnant again, 
notwithstanding extensive adhesion of the walls of the 
vagina, resulting from injury in her last confinement 
(insomuch that a probe could scarcely be passed fi:om 
the vulva to the uterus), he relates her despair, when 



ITS EFFICIENT CAUSE. 81 



the time of her delivery arrived, and expresses his own 
astonishment at the unexpected and poioerful effort^ by 
which a very robust child broke through the vaginal 
adhesion, making his triumphant entrance into the 
world, and leaving the way open for others who might 
foUow (1). 

This notion, so repugnant to reason and observation, 
is no longer defended by any one; and it is now well 
ascertained, that contraction of the uterus, aided hy that 
of the diaphragm and ahdominal muscles, is the efficient 
cause of the child's release from the womb. Of these 
agencies uterine contraction is the principal, as every 
one must be convinced, who has felt its power exerted 
upon his hand in a difficult case of turning. It alone 
performs the first stage of labor, which consists in the 
dilatation of the os uteri, preparatory to the passage of 
the child; and may, also, suffice for its expulsion, which 
has been seen to take place in cases of procidentia of 
the uterus, wherein the organ being entirely external, 
forming a large tumor between the thighs, could not 
receive the aid of the diaphragm and abdominal mus- 
cles (2). That the chief expulsive force resides in the 
uterus is furthermore proved by the number of instances 
in which the child has been born, and sometimes alive 
too, shortly after the sudden death of the mother fi'om 

(1) Opera Omnia, de Partu Exercitatio. 

(2) "Wimmer a vu 1' accouchement se faire d'nne maniere 
reguliere dans un cas on la matrice formait entre les cuisses une 
tumeur longue de dix pouces et demi et large de six et demi, dont I'ou- 
verture 6tait dirigee en has." (Burdacli'TraiU de Physiologie, 
traduitde rAUemand,j)ar A.J.L. Jourdan, Tmm IV, p. 204.) 

6 



82 LABOR, 



violence or spasmodic affection. Nieth (1) has collected 
a series of cases of this kind. 

It cannot be doubted^ nevertheless, that the abdom- 
inal muscles and diaphragm cooperate in the expulsion 
of the contents of the gravid uterus, in a subordinate 
manner. The learned Ilaller doubtless erred in ascri- 
bing to these secondary agents the principal, if not ex- 
clusive, office in expelling the fetus (2). To him it 
appeared that the fibers of the uterus are too feeble to 
produce the effects required of them, viz., to propel 
the fetus against considerable resistance, to compress its 
head into a long cone, to repel the os coccygis, &c., 
much more, to cause disruption of the joints of the 
pelvis, which sometimes happens in labor. With these 
he strongly contrasts the abdominal muscles and dia- 
phragm in the throes of labor, and is scarcely able to 
conceive how the delicate fibers of the uterus can act at 
all, under their overpowering compression. He concludes, 
therefore, that the uterus performs but a subordinate 
and indirect part in labor — a conclusion at which he 
could not have arrived, had his practical knowledge of 
obstetrics been equal to his profound erudition. We may 
consider these parturient powers separately; and First, 
Of uterine contractions as the chief efficient cause of labor. 

The uterus displays two distinct modes of contraction 
during labor ; one being intermittent and attended with 
pain, the other permanent and free from pain. The 
former consists in action of the muscular fibers of the 

(1) Diss, de partu post mortem, Berlin, 1827; quoted by Bur- 
doch, loc. cit. 

(2) Elementa Physiologia), Tom. VIII., Lib. xxix, sect. 6; 
causae partum efficientes. 



ITS EFFICIENT CAUSE. 83 

uterus, analogous to that of muscular fibers in other 
parts of the bodj, which is always alternated with in- 
tervals of repose, during which the fibers are in a state 
of relaxation: we may, therefore, denominate it the 
muscular contraction of the uterus, which seems to me 
more appropriate than ^*' paroxysmal" or "spasmodic," 
by which it is commonly distinguished. The latter, viz. 
the permanent contraction, results from contractility of 
tissue; a vital property that pervades all animal tex- 
tures — and it, as well as the former, occurs in the 
muscular tissue of the uterus. This is denominated 
the tonic contraction, and we may conceive that it is 
exerted chiefly in the intricate fibrous web that per- 
vades all parts of the uterus, while the muscular con- 
traction is performed by the several orders of fibers, 
whose arrangement has been described. 

These two modes of contraction are equally essen- 
tial, and each is worthy of our careful study. 

(A.) Of the muscular contraction. 

This may be studied analytically and synthetically, 
that is, we may first consider the efiect produced by the 
contraction of each order of fibers separately, and then 
the effect of their simultaneous contraction, as is known 
to occur in labor. 

In pursuance of this method, it is to be observed, in 
the first place, that contraction of the oUique filers 
draws the fundus toward the os uteri, or, in other words, 
shortens the axis of the uterus, and that in a more con- 
siderable degree than, supposing them to exist, longitu- 
dinal fibers could. To demonstrate the truth of this 
statement, let us take those fibers on one surface of the 



84 LABOR, 



uterus, the anterior, for example. The fibers from both 
sides of the organ, runniug obliquely upward and meet- 
ing on the medial hue, compose but a single muscle, of 
thepenniform kind, with the round ligaments for its fixed 
points. These Ugaments are to be regarded as its fixed 
points, in consequence of the connection of their lower 
extremities with the tendinous insertions of the abdom- 
inal muscles. J. Hunter, in his second Croonian Lec- 
ture on muscular motion, observes "that there are many 
half-penniform and complex muscles in the human body, 
but hardly one instance of a distinct complete-penniform 
muscle" (1). Ever since I have known the arrange- 
ment of the oblique fibers of the uterus, it has appeared 
to me that they constitute as perfect a specimen of such 
a muscle as anatomy has yet revealed ; and I shall ex- 
plain its action according to this view of its construc- 
tion, — making use of Mr. Hunter's diagram, intended 
to illustrate the principle of the action of this kind of 
muscles generally. 

c Let A C and B C represent two fibers 

/|\ of a penniform muscle in their extended 

/\\/\ state, A and B being their origin, and 
/ /*"\\ C the point of their insertion. Suppose 
^^ ""^ these fibers contracted to the points E 

and F, it is evident that such contraction will bring the 
point of insertion from C to G, and that the motion of the 
point of insertion will be to the contraction of the mus- 
cle as C G is to C F or C E; for A G is equal to A E, 
and B G is equal to B F, or A and B are the centers of 
the circles A G E and B G F. 



(1) Complete Works, edited by James F. Palmer; Vol. IV. 
Amer. edition, 1841. 



4 



ITS EFFICIENT CAUSE. 85 



From this demonstration, it is plain that the oblique 
fibers shorten the axis of the uterus more than any 
other disposition that could have been debased, and 
that the advantage gained is in proportion to their 
obliquity. 

Sir Charles Bell (1) observes that " this layer of 
muscular substance operating on the round Hgaments, is 
well calculated to assist in expelling the fetus ;" but 
he does not enter into any explanation of its action, 
unless it be included in his remarks on longitudinal 
fibers, and assigns to it other offices, which, he appears 
to think, more peculiarly belong to it. These offices 
are, to bring down the womb in the first stage of labor, 
and to give the uterus and the head of the child the 
right position with regard to the axis of the pelvis ; for, 
without its aid, he is at a loss to conceive how the ute- 
rus, by its own action, could adjust the position of the 
orifice for the dehverv of the child. 

In the second place, the contraction of the concentric 
circles of the body must cause the walls of this part of 
the uterus to approximate so as to diminish its cavity 
in every direction. The fundus of the uterus must at 
the same time be depressed by them, so that they as- 
sist the obhque fibers in diminishing the length of the 
uterus. Another use of these concentric fibers may be 
that attributed to them by Ruysch, viz., to detach the 
placenta, for which they appear to be well fitted, seeing 
the placenta is a ckcular mass, attached to the uterus 
most commonly over these fibers. 

In the third place, contraction of the circular fibers 

(1) Op. Cit. 



86 LABOR, 



of the neck diminishes its caliber, and closes or dimin- 
ishes its vaginal orifice. The bands of fibers mentioned 
by Sir Charles Bell, as running upon the internal surface 
of the uterus from about the mouths of the fallopian tubes 
to the OS uteri, may (if they exist ) perform the office 
ascribed to them by him, viz., that of drawing the low- 
er segment of the womb over the child's head ; but 
their existence, or that of any other fibers^ having such 
an office, is doubtful. 

Before we proceed to investigate the effect of the 
combined action of these several orders of fibers, it is 
necessary to prove that they are all excited to contrac- 
tion at the same time, as this has been denied by some, 
who contend that while those of the body contract, 
those of the neck are in a state of repose. 

That true parturient contraction of the uterus is gen- 
eral, is proved by observation, as any one may satisfy 
himself by placing his hand on the abdomen during a 
pain, when the organ will be felt everywhere hard and 
resisting ; and if, now, the finger be introduced within 
the OS uteri, the orifice will be found contracted at the 
same time. In the intervals of the pains, relaxation 
having succeeded to contraction, no such hardness is to 
be felt over the uterus, and its orifice may be easily di- 
lated, to a certain degree, by the finger. When it be- 
comes necessary to introduce the hand into the cavity 
of the uterus, additional evidence is obtained, which 
makes the proof as conclusive as can be desired; — 
while the hand is, during a pain, benumbed by the con- 
traction of the body, the orifice contracts, also, and acts 
as a stronar lio-ature round the wrist. 

The tendency of the simultaneous contraction of the 



ITS EFFICIENT CAUSE. 87 



fibers belonging to the body of the uterus, e^ddently is 
to cause the fetus to move in the direction of the os 
uteri. Proceeding from the round hgaments, and divi- 
ding into two layers that spread over the anterior and 
posterior surfaces of the fundus uteri, the oblique fibers 
of each side grasp the organ like a pair of hands, and 
as the round ligaments are their looints d' cq^iJid, they 
push down the fetus, while the concentric fi.bers prevent 
it from diverging in any direction. Could we imagine 
a section made across the body, at its junction with the 
neck, and the resistance of the bony pelvis to be re- 
moved, it is obvious that the fetus would be immedi- 
ately expelled from its cavity. 

But the neck resists, and resistance to the escape of 
the fetus is the alone effect of the contraction of its 
fibers; it is this that makes parturition necessarily labo- 
rious — hoc opus, hie labor est. 

Labor, then, according to our view of it, is a contest 
between the body and neck of the uterus, — the former 
aiming to expel the fetus, and the latter to retain it. 
This is no novel doctrine ; it was distinctly taught by 
the celebrated Levret (1), who maintained that, as the 
neck of the uterus is the antagonist of the body, during 
pregnancy, and serves to hinder the product of concep- 
tion fi^om being expelled, so the body is the antagonist 
of the neck, during labor, else the fetus could never 
escape; and if the neck prove too strong for the body, 
one of them must necessarily be ruptured. I shall 
hereafter attempt to explain how the battle is lost and 
won. 

(1) L'Art des Accouchemens, Troisieme edit., Paris, 1766, 
D. 89. 



88 LABOR, 



(B.) Of the tonic contraction. 

The term by which Baudelocque designated this ac- 
tion of the uterus, action de ressort, or elasticity, is ex- 
pressive of its character and uses. In virtue of this 
contraction, the uterus, in fact, constantly tends to re- 
sume its unimpregnated volume, whenever the cause 
that distends it is removed. 

It has been much disputed whether the gravid ute- 
rus really suffers itself to be distended by its contents, 
or enlarges with their growth, by a sort of active dilata- 
tion, so as to remain free from anything like mechanical 
distention during the entire term of pregnancy. 

M. Gardien (1) enters, at some length, into the dis- 
cussion of the question, and decides in favor of active 
dilatation. He thinks that the observations of Ber- 
trandi (who, in opening the bodies of women dying in 
the earlier periods of pregnancy, always found the cavi- 
ty of the uterus enlarged, although no fetus was con- 
tained in it) prove that its expansion is active, shortly 
after conception. Extra-uterine conceptions are, also, 
referred to by him in support of this view, because the 
uterus is known to acquire considerable magnitude in 
such cases, although no fetus or even deciduous mem- 
brane be contained in it. 

The increased volume of the uterus, prior to the 
descent of the ovum into its cavity, may, however, be 
easily explained by the determination of blood that 
takes place toward it, immediately after impregnation. 
And when extra-uterine conception occurs, even should 
no deciduous membrane be formed, the enlargement of 

(1) Traits Complet d'Accoucliemens, &c., Tom. I, p. 172. 



ITS EFFICIENT CAUSE. 89 



the organ may be ascribed to the same cause. But in 
far the greatest number of such cases, the cavity of the 
uterus is Hned by an organized membrane, and full 
preparation is made for the reception of the ovum. In 
such instances, the enlargement may be produced, in 
part at least, by the agency of its contents. According 
to M. Breschet (1), indeed, one of the uses of the fluid 
that fills the decidual sack, the hydro-perione, is gradu- 
ally to dilate the cavity of the uterus by acting with a 
moderate but regularly increasing force, and when the 
hydro-perione is consumed, the hquor amnii takes its 
place in this respect. 

Some, who contend for the active dilatation of the 
uterus during the first weeks of pregnancy, admit that 
it becomes somewhat passive toward the last, — the or- 
gan being sohcited by the hquor amnii to dilate activety. 
But even this mollified mechanical agency does not meet 
with favor fi^om M. Gardien, for if we do not admit, says 
he, that the uterus possesses the faculty of distending 
itself actively J it is impossible to conceive how the force, 
that pushes additional fluids into the amniotic sack, can 
surmount the resistance which the fluid, already con- 
tained there, makes against the mouths of the exhaling 
vessels, seeing this fluid reacts with equal force upon all 
points of the internal surface of the uterus. In other 
words, the pressure of the ovum that dilates the ute- 
rus ought, in M. Gardien's estimation, to stop the 
mouths of the uterine exhalants, and thus arrest the 
progress of dilatation by cutting off the supply of the 

(1) Memoires de F Academie Koyale de Medicine, Tom. 
deuxieme. 



90 LABOR, 



fluid dilator, — an objection more specious than solid. 
Why, it may be asked, is not the progress of dropsical 
effusion into the various cavities of the body arrested 
on the same principle, if it be really a valid one ? The 
truth is, there is no degree, compatible with the preser- 
vation of vitality, to which the distention of animal tis- 
sues can be carried, but exhalation, as well as other 
vital actions, will still go on. 

Lastly, M. Gardien alleges that mechanical disten- 
tion would destroy the contractile power of the uterus, 
as it is known to do that of other muscles. But there 
is a wide difference between the gradual distention of 
the uterus, solicited by its contents, with which the 
growth of the organ keeps pace, and the forcible stretch- 
ing of muscles to which he refers. Upon the whole, it 
appears that pregnancy establishes a genuine hypertro- 
phy in the uterus, affecting all its tissues, and thus fits 
it for undergoing the degree of distention required by 
the ovum, — this distention taking place according to its 
requirements, and therefore under a sort of coercion, not 
by any imaginary faculty of active expansion. 

Be this as it may, the uterus, in the exercise of its 
tonic contraction, acts as though it had been distended ; 
for in proportion as the fetus is expelled, its tissue is 
permanently condensed, and its cavity diminished, until 
but little of it remains after its depletion. Nor is this 
all. Even before the fetus begins to be expelled, the 
tonic contraction is brought into operation. The mus- 
cular contractions, it is true, cannot, before the rupture 
of the membranes, reduce the volume of the uterus in 
any considerable degree, on account of its contents be- 
ing nearly incompressible 5 but to whatever degree this 



ITS EFFICIENT CAUSE. 91 



reduction may be carried, when the muscular contrac- 
tion subsides, the tonic interposes and prevents the or- 
gan from relapsing to its former dimensions. Some per- 
manent advance is thus made toward diminishing the 
size of the organ. 

After the rupture of the membranes and escape of 
a portion of the waters, the tonic contraction has a fairer 
chance, if we may so express it, to display itself The 
cavity of the uterus is not then filled by the fetus, and 
its walls would hang flabby and relaxed about it but for 
the tonic contraction, which tightens and brings them 
into contact with the fetus, and succors the muscular in 
expelling it. This succor is rendered by maintaining 
the ground gained by each successive muscular contrac- 
tion, without which it is diJfficult to conceive how the 
expulsion could be achieved at all. In truth, it could 
not be, unless a single muscular contraction were suffi- 
cient; for, upon its subsidence, the uterus would relapse 
to its former dimensions, and the fetus recede. In or- 
der that any number of muscular contractions may ex- 
pel the fetus, it is, therefore, necessary that some means 
be devised to secure the advance made by each, and 
the tonic contraction is the means appointed for this 
purpose, Avhich, besides rendering this indispensable aid, 
protects the woman against hemorrhage afterward, by 
diminishing the caliber of the utero-placental vessels. 

Secondly; Of the contractions of the diaphragm and 
abdominal muscles, as accessaries to labor. 

Although the diaphragm and abdominal muscles are 
but auxiliary forces during labor, yet they render very 
efficient service, especially in the second stage, when the 



92 LABOR, 



fetus comes to distend the os uteri and vagina, and by 
its pressure, excites sensations, comparable to those pre- 
ceding the evacuation of the rectum and bladder, called 
by Baudelocque "le besoin de se deUvrerJ' A glance at 
the physiology of the effort, which they make, will be 
sufficient to convince us of its utility. 

The diaphragm is the principal muscle of respiration. 
In its quiescent state it is arched above, but in contract- 
ing it becomes more plain, and the longitudinal capacity 
of the chest is increased, while that of the abdomen is 
diminished, and consequently its viscera are pressed 
downward. 

The abdominal muscles are chiefly concerned in ex- 
piration, being in a state of relaxation while the dia- 
phragm is contracting, and by yielding they make room 
for the viscera pressed upon by the diaphragm. But 
when they contract, the diaphragm relaxes, and, yield- 
ing in its turn, is pushed upward into the cavity of the 
thorax. 

Thus we see that in respiration the abdominal vis- 
cera are not forcibly pressed upon, the alternate con- 
traction and relaxation of these two sets of muscles 
securing the cavity, that contains them, from any mate- 
rial variation of its capacity. But in labor, both sets of 
muscles are called into action at the same time: first, 
the diaphragm contracts, causing a full inspiration; be- 
fore it relaxes, the abdominal muscles contract, and, the 
exit of the au^ from the lungs being prevented by the 
closure of the glottis, the abdominal viscera are sub- 
jected to the pressure of their joint forces. This com- 
pound pressure, acting upon the uterus, propels the fetus 



ITS EFFICIENT CAUSE. 93 



in the direction of the pehdc outlet, because such is the 
resultant of the forces producing it (1). 

Writers are generally agreed as to the instrumen- 
tality of the diaphragm and abdominal muscles during 
labor; but according to the researches of MM. Cloquet 
and Bourdon, as we learn from M. Cazeaux (2), the 
diaphragm does not exert any active pressure upon the 
superior part of the uterus, but, sustained by the re- 
sistance of the air in the lungs, its contraction fixes the 
base of the chest, and thus affords sohd "points d'appui" 
to the insertions of the abdominal muscles, which alone 
are active in expelling the fetus. 

The fixedness of the thoracic parietes gives, doubt- 
less, greater efi&cacy to the contraction of the abdominal 
muscles, as then whole force is expended in pressing 
upon the uterus, instead of drawing down the ribs, as in 
expiration; but I am not able to understand on what 
grounds an active agency can be denied to the diaphragm. 
If it be admitted that its contraction is simultaneous 
with that of the abdominal muscles, it must press down- 
ward, or at right augles with those muscles, and thus 
cause the fetus to move in the diagonal of the two 
forces, which, as already stated, is in the dnection of the 
inferior apertm^e of the pelvis. 

But, besides this propelhng agency, the abdominal 
muscles and diaphragm are subservient to labor, by em- 
bracing and supporting the uterus while it is in action. 
The support, thus rendered, is a great protection 

(1) G-ardien, Traits Complet d'Accouchemens, Tom. 2, p. 210. 

(2) Traite Theorique et Pratique de I'Art des Accoucheniens, 
p. 265. 



94 LABOR, 



against ruptures, while it excites the organ to increased 
energy of parturient contraction. Who does not know 
that firm pressure upon the uterus, through the abdomi- 
nal walls, is our main reliance to excite its contraction, 
in cases of hemorrhage from inertia after delivery? 



ITS DETERMINATIVE CAUSE. 95 



CHAPTEE VI. 
OF THE DETERMINATIVE CAUSE OF LABOR. 

The determinative cause of labor is that which 
brings into operation the expulsive contractions of the 
uterus and its auxiliaries ; it may, therefore, be properly 
denominated the "exciting" cause of labor, and I shall 
accordingly designate it by this epithet as well as by 
the other. 

What is it that excites the uterine contractions, 
when gestation arrives at its term ? This inquiry has 
been considered as impracticable, if not impious: thus, 
one of the latest French writers, M. Chailly, after allu- 
ding to the views of various authors, says, " I do not 
insist upon these various causes ; for none of the theo- 
ries advanced is entirely satisfactory, and we are com- 
pelled to return with M. Yelpeau, to the opinion of 
Avicenna : " At the proper time, delivery takes place 
by the grace of God" (1). Dr. Dewees, too, com- 
mences his chapter on the " Cause of Labor," (in which 
there is much ink shed to little purpose ) in the same 
strain: "Avicenna, centuries ago, declared that labor 
was a law of God, and that it came on at the appointed 
time. I would ask, has any hypothesis since that pe- 

(1) Practical Treatise on Midwifery, translated by Gr. S. Bed- 
ford, M. D. ; New York, 1844, p. 168. 



96 LABOR, 



riod, enliglitened us more upon this subject than the 
humble confession of this good old man?" 

Labor does, indeed, take place by the divine ap- 
pointment ; but this is carried into effect by the opera- 
tion of secondary causes, and it is not more presump- 
tuous to inquire into these than into the causes of the 
numerous other phenomena by which we are surrounded. 
We cannot but think, therefore, that there is more piety 
than philosophy in Avicenna's hackneyed apothegm, 
and more indolence than learning in quoting it. 

Baudelocque's theory of the induction of labor, is 
nearly allied to that by which he explained the peculiar 
development of the uterus during pregnancy; it is, in 
fact, only an extension of the same principle. He con- 
tends that the determinative cause of labor, at the end 
of gestation, resides in the uterus itself; that this cause 
acts constantly during pregnancy, although its effects 
are not usually sensible until the end of nine months ; 
that, every moment, the developed uterine fibers are 
urged to expel the fetus, which affects them disagreea- 
bly; that, if they do not expel it at an earlier period, it 
is owing to their not being all equally urged, because, 
as all are not developed at the same time, the action of 
some is strongly counterbalanced by the natural resis- 
tance of others. The structure of the organ is such that 
the neck resists, during the first six or seven months of 
pregnancy, while the fibers of the body obey, the agents 
that distend and develop them: but toward the end 
of pregnancy, the fibers of the neck, becoming more 
supple, alone supply the necessary expansion, so that in 
less than two months, this part is entirely obliterated, 
and is so enfeebled that it can no longer sustain the 



I 



ITS DETERMINATIVE CAUSE. 97 



efforts of the body. It is then that the latter exert a 
sensible action upon the product of conception, and push 
it forward ; if this action is not painful to the woman, 
its effects are discoverable by the finger, introduced to 
the uterine orifice and apphed to the membranes. This 
is the first degree of labor, although the commencement 
of strong pains is usually reckoned as such. The time 
for these pains is not far distant; more powerful con- 
tractions of the uterus soon succeed this species of 
prelude (1). 

There is no evidence of such contractile efforts of 
the uterus as this theory assumes, except the occasional 
tension of the membranes, sometimes observed toward 
the completion of gestation, ih^ os uteri being then suf- 
ficiently open to admit the finger. Slight contractions 
of the fundus may produce this tension, but these are 
not such as constitute labor, for they are unaccompanied 
by pain, and take place without the consciousness of the 
individual herself Allowing, however, that they are 
laborpains in disguise, their presence at so advanced a 
period of pregnancy is no proof of their existence during 
the earlier periods: and in the complete absence of such 
proof, we are loth to admit the assumption that they 
do exist, because it makes the uterus the strangest 
anomaly in the body, if not in nature. It is destined 
first to contain and nourish the fetus, and then to expel 
it, when its maturity is acquired. But, according to 
this assumption, the first is an irksome task imposed 
upon it which it continually endeavors to quit by expel- 
ling its contents. Such a constitution of the gestative 

(1) L'Art des Accouchemens, par. 584-5-6-7. 

7 



98 LABOR. 



organ could hardly exist, and abortion be not perpetu- 
ally threatened, without, as far as we can perceive, any 
compensating benefit ; for we cannot imagine that its 
development could be promoted by it. There is, in 
fact, no conceivable v^ay in which contraction of the 
uterine fibers during pregnancy could favor their devel- 
opment, except that imagined by Baudelocque, viz., one 
class of fibers stretching another by the superior force 
of their contraction, by which he attempts to account 
for the development of the cervix uteri. How, then, 
are the fibers of the body of the uterus developed du- 
ring the first six or seven months of gestation, the neck 
being quiescent all the while ? If these need no such 
force to aid their development, neither do those of the 
neck : both are developed after their own peculiar fash- 
ion, without the interference of one with the other. 
The neck, as we have seen, is developed in women who 
have borne children, in a manner inconsistent with the 
idea that any sort of force is exerted upon it by the 
body, that is, from below upward. If, therefore, there 
is no evidence of the existence of these insensible con- 
tractions of the uterus, and, from the nature of the case, 
none can be acquired, until the os uteri is somewhat 
open, may they not be excited at this time in some way 
unknown to Baudelocque ? And is not that which ex- 
cites them the determinative cause of labor ? 

M. Adelon (1) indorses the theory which we have 
been examining, and which he ascribes, no doubt cor- 
rectly, to Ant. Petit, with the declaration that it is now 
universally received. " The mode in which the uterus 

(1) Pliysiologie de rHomme, secondc edit. Tom. lY, p. 123. 



ITS DETERMINATIVE CAUSE. 99 



is deTeloped/' says this learned physiologist, "must ne- 
cessarily bring on labor. In fact, only the fundus and 
body enlarge at first; the cervix is the last to become 
dilated in its turn, its dilatation being such that it be- 
comes as thin as a sheet of paper: henceforth, the equi- 
librium between the fundus and cervix is completely 
broken, and the continual retraction of the uterus kre- 
sistibly pushes the ovum against the cervix, opens the 
orifice, and engages the child in it." But, as if sensible 
of the insufficiency of this irresistiUe cause of labor, he 
seeks for adjuvants in the vital properties of the uterus, 
and in certain changes that take place in the placenta, 
the oro'an of attachment of the fetus. With reo-ard to 
the first he alleges, that the susceptibility of contraction 
gradually augments during pregnancy, until in the end, 
the sliohtest irritation is sufficient to excite it into 
action. As to the second, he asserts that the placenta 
receives at first, with great facility, the blood both of 
the umbilical and uterine arteries; but that, in the pro- 
gress of gestation, some of its vessels are obliterated, 
and it becomes less accessible to the blood that flows 
toward it: a congestion of blood consequently takes 
place, particularly in the uterus, which proves a sufficient 
stimulus to excite its contractions. The congestion, 
according to M. Adelon, is slight at first, and the ute- 
rine contraction that it provokes, dissipates it by forcing 
the surplus blood into the collateral vessels ; but recur- 
ring incessantly, and increasing on account of the gra- 
dual maturation of the placenta (that is, obliteration of its 
vessels), the uterine contractions are also incessantly 
renewed, until at last they are so multiplied that labor 
is established. 



100 LABOR. 



To prove that the congestion, which is asserted to 
exist, is capable of producing the effects ascribed to it, 
M. Adelon refers to the efficacy of even small abstrac- 
tions of blood, in preventing habitual abortion, to the en- 
feebling influence of large hemorrhages over the uterine 
contractions, and to the continuance of contractions after 
delivery, until the uterus is disgorged of blood. 

It will not be denied that the vital properties of the 
uterus, its sensibility and contractiHty, are highly ex- 
alted by pregnancy; nevertheless, it would remain in a 
state of inertia, unless it be aroused to action by some 
appropriate stimulus. This is admitted by M. Adelon, 
who thinks he finds an appropriate stimulus in the blood, 
by which, he supposes, the organ is surcharged in con- 
sequence of an interruption to its free circulation through 
the placenta. The assertion, however, that a part of 
the vessels of the placenta become impermeable, as the 
time of its separation draws nigh, is altogether gratui- 
tous. M. Adelon has not stated the evidence on which 
it rests, and I know not that any one pretends to have 
discovered obliterated vessels in the placenta; but I do 
know that, when cast off at the period of delivery, it is 
abundantly vascular, and that every part of it is pene- 
trated and distended by injections thrown into it. But 
supposing that some of its vessels are obhterated, this 
must take place gradually^ and could not the blood, 
that had circulated through them, be passed off by the 
collateral vessels, without the intermediate agency of 
uterine contractions? When the course of the blood in 
a large vessel, in other parts of the body, is suddenly 
interrupted by a ligature, it flows into coUateral channels 
without any extrinsic help. Is the uterus less able to 



ITS DETERMINATIVE CAUSE. 101 



protect itself against contingencies than other organs? 
It ought to be more able, if its office necessarily exposes 
its circulation to the interruptions supposed, for in that 
case the interruption is not accidental but natural, and 
nature quahfies an organ for the office she commits 
to it. 

Let it be conceded, finally, that some of the placen- 
tal vessels do become impervious, and that the uterine 
tissues are surcharged with blood, because the collateral 
vessels here cannot aid, as they do in other parts of the 
body, what proof have we that a mere redundancy of 
blood can excite the uterine fibers to contraction? It 
is true, that when the uterus is excited to action, an 
afflux of blood is invited to it, and its vascular activity 
is increased. But here increased vital action precedes 
the congestion, and is not produced by it. We cannot 
conceive, indeed, how a mere surplus of blood from re- 
mora can have any other effect then to oppress the 
vessels that are overloaded by it. 

Without consuming more time with learned and in- 
genious speculations, I proceed to state what I beheve 
to be the real exciting cause of labor, at the completion 
of uterine and fetal development, which is irritation of 
the cervix^ and especially of the as uteri, arising from 
the contact of the ovum ivitli it. Dr. John Power (1), 
the author of this theory, proposes to distinguish, by 
the phrase ^* orificial irritation,'' that state of the cervix 
which first awakens the partmient contractions of the 
uterus, and I shah adopt the term, for the sake of its con- 
venience. To show that the uterus is not singular in 

(1) Midwifery, second edit., London, 1823. 



102 LABOR, 



being aroused to action in this manner. Dr. Power ob- 
serves, that '^ every organ of the body is excited into 
proper action by a stimulus or exciting cause : the eye by 
the irritation of Hght ; the ear by the impulse of sound ; 
the voluntary muscles by mental stimuh ; and the in- 
voluntary organs by their peculiar stimuli, as, for in- 
stance, the heart by the irritation of the circulating 
blood ; the rectum by feces ; the bladder by urine, and 
the uterus by the stimulus of its contents." He re- 
marks, furthermore, that "all organs which are intended 
to retain for a time, and afterward expel, then' peculiar 
contents, are furnished with sphincters placed at their 
evacuating orifices. The most remarkable of these are 
the rectum, the bladder, and the uterus." 

Having proposed and illustrated our doctrine of the 
determinative cause of labor, I proceed to prove it, or, at 
least, to adduce such facts and arguments in support of 
it, as render it much more credible than the theories we 
have examined, or any others that have been suggested. 
Some considerations may first be mentioned which 
create a strong presum^otion that it is in this way that 
the uterus is excited to parturient contraction. 

First ; The j^emliar manner in wJiich the uterine 
neclc is unfolded during pregnancy. It has been shown, 
in a previous chapter, that the neck of the uterus does 
not participate in the changes going on in the body, 
having for their object amplification of the cavity, but 
remains quiescent for a considerable time, and then un- 
dergoes changes peculiar to itself; that its unfolding, 
so as to admit the ovum into contact with it, is deferred 
to a very late period of pregnancy, until, in fact, a short 
time before labor sets in. What other use can be as- 



ITS DETERMINATIVE CAUSE. 103 



signed for this singular deportment than that of guard- 
ing the neck from premature mitation, which might en- 
danger the premature expulsion of the ovum ? If it be 
objected, that such a peculiar mode of development of 
the cervix is not established by sufficient observation, 
and the account formerly given of the matter be pre- 
ferred, still the order in which the uterus is developed, 
even according to that account, — viz., the body ex- 
panding for the first six months, and the neck, during 
the last three months, from above downward, — would 
appear to have no other object than to screen the entire 
neck from the ovum for two-thirds of the period of 
pregnancy, and the os uteri until a short time previous 
to its full term. If the neck have no special offices to 
perform, and is onl}^ required to contribute its quota to 
the aggrandizement of the uterine cavity, why is it, or 
why should it be, so tardy in complying with the re- 
quirement ? He must be puzzled to answer this ques- 
tion, who denies that the cervix has any special offices 
to perform, and the particular one, too, which our doc- 
trme ascribes to it. 

The force of the inference in favor of the doctrine of 
"orificial irritation," deduced from the peculiar mode in 
which the neck is developed, is corroborated by the con- 
sequences resulting from a deviation from it. It has 
been heretofore shown, on the high authority of MM. 
Baudelocque and Gardien, that premature unfolding of 
the neck leads inevitably to premature expulsion of 
the contents of the uterus. How is this to be explain- 
ed upon any other principle than that of orificial irrita- 
tion ? It cannot be alleged that the body of the ute- 
rus continually endeavors to expel the ovum, and that 



104 LABOR, 



the neck is unfolded by these efforts, for it has been 
proved ah-eady that no such active efforts are made by 
the body during pregnancy. 

Secondly ; The rectum and bladder being excited to 
expel their contents by irritation of their orifices, affords 
strong ground of presumption that the uterus is excited 
to action on the same principle. It is hardly necessary 
to prove that the feces and urine are expelled in con- 
sequence of the irritation their accumulation produces 
at the anal and urethral orifices of the rectum and blad- 
der. The reality of such irritation is certified to every 
individual, by the internal or organic sensation that ac- 
companies it, which, like all other organic sensations, it 
is difficult to describe or even accurately to locate. We 
are, nevertheless, conscious of its existence, and may 
satisfy ourselves, by attending to it, that it is seated in 
the lower part of the rectum or bladder. When this 
irritation acquires a certain degree of intensity, it irre- 
sistably provokes expulsive contractions of the muscular 
fibers of the bladder or rectum. 

The uterus may, I had almost said must, be presum- 
ed to be excited to expel the fetus on the same princi- 
ple, because it is intimately associated with the rectum 
and bladder, and receives its nerves, in part, from the 
same sources. It will be remembered that it was 
stated, on the authority of Dr. Lee (whose observations 
on this point only confirm those of Tiedemann and 
others), that the ganglia upon the cervix uteri, com- 
posed of spinal and sympathetic nerves, distribute 
branches equally to the uterus, vagina, bladder, and rec- 
tum. It is difficult to resist the conclusion that organs, 
which receive their nerves from the same source, have 



ITS DETERMINATIVE CAUSE. 105 



an essential identity of functions to perform. Like tlie 
rectum and bladder, the uterus is moreoyer constrained 
to call in extraneous aid at a certain period of parturi- 
tion, and this aid is afforded it by the same powers 
which the rectum and bladder invoke, viz., the dia- 
phragm and abdominal muscles, which render like effi- 
cient service in defecation, micturition, and parturition. 

Whether the uterine orificial irritation that excites 
parturient contractions is attended by sensation^ anala- 
gous to that of the rectum or bladder, it may be diffi- 
cult to determine. I strongly suspect that it is; but 
this, like its Idndred sensations, is so exceedingly vague 
that it can hardly be defined by those who are the sub- 
jects of it. Females will not be apt to speak of it, un- 
less closely questioned ; and even then all they could 
say would be that uneasiness is experienced in the re- 
gion of the uterine neck. Is not such uneasiness some- 
times complained of among other premonitory indica- 
tions of the approach of labor? Be this as it may, 
however, sensation cannot be considered as essential to 
the existence of such orificial irritation as may serve to 
stimulate the uterus to action. 

We need not dwell longer on presumptive evidence, 
when demonstrative proof of the truth of our doctrine 
is within reach. Here it is: The uterus can he excited 
to ex^ndsive contractions, especially in the latter months 
of pregnane!/, hy artificial irritation of its orifice. This 
artificial irritation is estabfished by the introduction of 
a finger within the orifice, and pressing upon its ckcle 
to stretch or dilate it. The knowledge of this fact 
led M. Puzos, a century ago, to propose his memorable 
innovation upon the previously-established practice in 



106 LABOR, 



cases of flooding, occurring in the latter months of 
pregnane}^ The method of Puzos did not consist in 
merely rupturing the membranes, as it has been repre- 
sented by nearly all succeeding writers, but in first in- 
ducing labor, where it does not exist, or strengthening 
it, where it is too feeble, by dilating the orifice with the 
fingers, as gently as nature is accustomed to proceed in 
ordinary cases ; and when the orifice is somewhat dila- 
ted, and the membranes are rendered tense by the pains, 
in rupturing them to enable the contracting walls of the 
uterus to diminish the caliber of the bleeding vessels, 
as the liquor amnii flows away. 

To rupture the membranes, when there is no or but 
feeble parturient action of the womb, would only ex- 
pose the woman to increased hazard from hemorrhage, 
and yet, it would be easy to show, if this point of prac- 
tice were our theme, this has been repeatedly done by 
renowned practitioners, under the pretended sanction of 
Puzos's authority. On this important subject^ I can 
render no greater service than by earnestly recommend- 
ing tvriters, as well as practitioners, to peruse carefully 
Puzos's " Memoir e sur les Pertes de Sang,'' first publish- 
ed in the second volume of the Memoirs of the Royal 
Academy of Surgery, in 1743, and subsequently in his 
posthumous works, entitled " Traite des Accoiichemens, 
Paris, 1759. 

But not only may parturition be induced by orificial 
irritation, artifically excited, but when labor has com- 
menced naturally, if the uterine contractions be languid 
and inefficient, they may be made stronger and more 
effective in the same way. The principle is, therefore, 
susceptible of useful practical application, in the man- 



ITS DETERMINATIVE CAUSE. 107 



agement of lingering labors, occurring under certain, 
well-defined circumstances, which it will be my duty to 
point out hereafter. Nor is this all. Many interesting 
phenomena are occasionally observed, in the progress of 
labors, which serve to confirm our doctrine, and can be 
explained on no other principle. These will be noticed 
as they come up in the course of this volume, and I 
shall not fail to derive from them whatever support they 
are fairly entitled to yield. 

Notwithstanding the weight, and, to my own mind, 
conclusiveness, of the testimony that has now been ad- 
duced, in support of the doctrine of orificial irritation, 
objections have been raised against it, as they may easily 
be against any doctrine, or even the plainest matter of 
fact. Dr. Dewees criticizes it at considerable length, in 
his chapter on the Cause of Labor; but his criticism is 
more plausible than profound, and derives much of its 
edge fi-om mistaken notions and gratuitous assertions 
concerning the economy of the gravid uterus. Assert- 
ing, for example, the existence of an expulsive nisus, in 
the body and fundus of the uterus, during pregnancy, as 
an undeniable and admitted fact, and holding the com- 
monlj^-received opinion, that the cervix begins to ex- 
pand at the sixth month, to make room for the o^oim; 
he objects that the propulsion of the ovum against the 
sensitive cervix, by the contractions of the fundus and 
body, ought to produce premature expulsion much more 
frequently than it actually occurs, if the doctrine in 
question be true. And so it ought, of this nisus were 
not itself a chimera, and the account which he gives of 
the development of the cervix fallacious. 

But there is one objection urged by Dr. Dewees, 



108 LABOR. 



wliicli merits a moment's consideration, because it pre- 
sents a seeming dilficultj, that might prove embarrass- 
ing to some. It is thus stated by him ; " Labor ensues 
sometimes before the entire obUteration of the neck 
takes place, and does not necessarily ensue immediately 
after it is completely efilxced; nay, the mouth of the 
uterus will sometimes be opened to some extent for 
days, now and then even for weeks, without the partu- 
rient effort declaring itself" Let us examine the posi- 
tive and negative poles of this objection, and try whether 
it be as shocking as the doctor imagined. 

First. It is certainly true, as he alleges, that various 
causes, such as the death of the fetus, blows, falls, ergot, 
drastic purgatives, etc., may excite premature expulsion 
of the ovum, without acting directly upon the sensitive 
OS uteri; nay, abortion is so much more painful and 
difficult than labor at term, partly because the cervix 
must first be developed, and then its resistance overcome 
by the expulsive contractions. The exciting causes 
appear to act by producing morbid irritability of the 
muscular fibers of the uterus, in consequence of which 
they are aroused to contraction by the mere presence of 
the ovum, even if the fetus be alive, much more if it be 
dead, because it then acts as an extraneous body. This 
only proves, however, that the uterus may be excited to 
expel its contents in another mode beside the normal 
one, nor is it at all singular in this respect. The intestines 
and urinary bladder are ordinarily excited to expel their 
contents, by sensible irritation referred to their orifices 
respectively ; but in morbid states, as, for instance, when 
their mucous membranes are irritated or inflamed, they 
are thrown into contraction by the direct stimulus of 



ITS DETERMINATIVE CAUSE. 109 



the feces and urine, and diarrhea or strangury is the 
consequence. Abortion may be said to be strangury of 
the uterus; its occurrence proves, at any rate, that the 
uterus is in a morbidly irritable condition. As well^ 
therefore, might it be argued that irritation of the ori- 
fices of their emunctories is not necessary for the evacua- 
tion of the feces and urine, in a healthy state, because 
they are otherwise ejected in diarrhea and strangury, as 
that orificial irritation is not the usual medium through 
which the uterus expels the fetus, because it is other- 
wise expelled in abortion. 

Secondly. It must hkewise be admitted, that partu- 
rient contractions are not always, or even generally, ex- 
cited, immediately after the cervix uteri is fully expanded 
and the ovum brought into contact with the os tincse. 
Om' own experience testifies to the fact that several days 
may elapse before the occurrence of labor, although the 
cervix may be obHterated and its orifice be somewhat 
open. But it does not follow, in any case, that a cause 
is inoperative because its effect is not immediately pro- 
duced : on the contrary, a longer, or shorter interval, 
according to the nature of the cause, must be allowed, in 
most cases, before the effect ensues. To borrow an 
illustration from medicine. Tartar emetic, introduced 
into the stomach, will excite vomiting in fifteen or tiventy 
minutes^ epsom salts will purge in two or three hours^ 
and calomel in ten or tivelve. The same cause, more- 
over, may requke different periods of time to produce 
its peculiar effects on different individuals, as is noto- 
rious with regard to miasmata and animal poisons. 
When therapeutists shall discover why tartar emetic, 
salts, and calomel, do not operate instantly, and patho- 



110 LABOR, 



legists explain why the same causes of disease have 
different periods of incubation in different individuals, 
obstetricians should bestir themselves to discover why 
a longer or shorter contact of the ovum with the os 
uteri is required in different individuals to excite labor. 

There is another objection, offered by Dr. Dewees, 
which ought not to be passed over in silence, lest it 
should be taken for granted that it is entitled to the 
stress which he has laid upon it. He affirms that, in 
cases of extra-uterine pregnancy, the uterus takes on 
regular parturient action, at the period when gestation 
naturally ceases, because the deciduous membrane, 
which lines the uterus in these cases, as well as in ute- 
rine gestation, loses its vitality at this time, by a law of 
nature, and must be expelled as a foreign body. From 
the tenor of his remarks, the reader is left to infer that 
well-marked labor comes on at about the regular time, 
in extra-uterine, as in normal, pregnancy. Admitting, 
for argument's sake, that this statement is correct, it 
only proves that the uterus may be excited to contract, 
hy the direct irritation resulting from the presence of a 
foreign body in its cavity. It is probable, moreover, 
that the decidua does not become fully organized, and 
that, having no office to perform, it loses its vitality, 
and becomes more completely a foreign body than it 
ever does in utero gestation. 

But the uterus is not always lined with decidua, in 
extra-uterine pregnancy ; nor, in a large number of 
cases, does any pain o(cur that can be referred to the 
uterus. It is well known that if the fetus be lodged in 
one of the fallopian tubes, the c}'st containing it is rup- 
tured at an early period of pregnancy, the fetus escapes 



ii 



ITS DETERMINATIVE CAUSE. m 



into the abdominal cavity, and the woman dies of inter- 
nal hemorrhage, to which is superadded peritonitis, if 
the accident be not speedily fatal. Before this catas- 
trophe takes place, she may have frequent attacks of 
violent pain; but the pain is the consequence of disease, 
not of labor, and uterine contraction has no share in 
producing it. When gestation is protracted to the ninth 
month, or later, as it may be in the ventral species of 
extra-uterine fetation, pains occur resembhng labor, 
which may be partly uterine, as they are accompanied 
with a sanguineous discharge fi^om the genital organs; 
but much of the tenesmus and bearing down complained 
of, is undoubtedly produced by the pressure of the cyst 
upon the pelvic viscera. In other instances, the pain 
is referable to the cyst itself, which alternately contracts 
and relaxes like the uterus, whose functions in other 
respects it provisionally performs. This is doubted or 
denied by Dr. Dewees; but he ought to have remem- 
bered that Baudelocque, to whom he professes so much 
indebtedness, and from whom to differ he declares to 
be so very unsafe, verified this fact beyond all doubt in 
one of the cases recorded by him ( 1 ). 

(1) "Le kyste renfcrmant le foetus se contraetoit comme le fait 
lamatrice; il s'arrondissoit et se durcissoit pendant ces douleurs, 
puis il se detendoit et se relaehoit. On pouvoit, en Tobservant 
attentivement d'une main placee sur le ventre, annoneer le douleur 
qui alloit se faire sentir, sa force et son declin. Malgre leur 
recidine assez frequeute, durant plusieurs jcnrs, I'etat du col de la 
matrice ne changea point. L'orifice externe ou vaginal ne s'ouvrit 
pas au d.l a de ce qu'il etoit d'abord, et I'interne demeura con- 
stamment trop etroit pour admettre le doigt. II n'j eut aucune 
espece d'ecoulement, d'exsudation, ni de sang, ni d'eau, ni de mu- 
cosites; tontes ces parties resterent seclies." — {L\Art des Ac- 
couchemens, par. 2235.) 



112 PHENOMENA OF FIRST STAGE OF LABOR. 



CHAPTER VII. 
PHENOMENA OF THE FIEST STAGE OF LABOE. 

The phenomena of labor are the sequences of the 
causes, which we have been considering. For the pur- 
pose of classifying these sequences, as well as with 
a view to practical utility, labor is usually divided into 
several stages. I prefer the division into three stages, 
which will be adopted without criticising the merits of 
other classifications that have been proposed. The first 
sta2;e extends from the commencement of labor to the 
complete dilatation of the os uteri; the second stage 
embraces the expulsion of the fetus, — the third, the de- 
tachment and expulsion of the secundines. 

The first stage of labor is characterized by four prin- 
cipal phenomena, which it will be my object to elucidate 
in this chapter. 

1. Pains. The muscular contractions of the uterus 
are so invariably accompanied with pain, that it is not 
surprising that the effect has been confounded with its 
cause, and has received credit for all the efficiency ex- 
erted in labor. Hence, the terms, pains, laborpai7is. 
uterine contractions, are used metonymically by obstet- 
rical writers and practitioners, — a usage which I shall 
respect, because it is often convenient, and cannot mis- 
lead, if it be remembered that, when used in this sense, 
pains has no reference to the sufferings of the patient, 
which may be excruciating, in nervous or susceptible 



PAINS. 113 



individuals, although the pains are trifling, that is, inef- 
ficient. 

The uterine contractions are not accompanied with 
pain m the first stage of labor only, but also in the sub- 
sequent stages; it is, nevertheless, to be observed that 
the character of the pain is different in the different 
stages. In the first stage (with which alone we are 
concerned at present) it is described as cutting or grind- 
ing, and as not unfrequently continuing, during the 
intervals of the contractions, in a sufficient degree to 
worry the patient. From this cause, together with the 
absence of consciousness that these pains are accom- 
plishing any thing, she is fi-etful, impatient, agitated, 
and desponding; and from her behavior, the experienced 
accoucheur may form his judgment of the stage of labor 
under which she is suffering. 

We are not to imagine that the uterine contraction, 
in any of the stages of labor, is in itself any more pain- 
full than muscular contraction in other parts, for exam- 
ple, in the abdominal muscles, bladder, or rectum. In 
the first stage, the pain appears to be seated in the 
cervix uteri, and is owing to the resistance it opposes 
to the contractions of the body, which, notwithstanding, 
are powerful enough to distend and stretch it. 

Such is the explanation given by Madame Boi™, 
whose opinion, on a point at once so delicate and vague, 
is entitled to great deference, considering that she was 
both an accomphshed sagefemme and a fruitful mother. 
Madame Boivin says, "we dare affirm, and our sensations 
have not deceived us, that, when the contraction begins 
and while it lasts, the woman experiences only a pres- 
sing sensation, more or less strong, which seems to 
8 



114 PHENOMENA OF FIRST STAGE OF LABOR. 



originate along the mesial line of the posterior wall of 
the uterus, and extend round its sides to the anterior 
mesial hne, which rises, becomes hard, and distends the 
middle of the abdominal walls. This uniform pressure 
throughout the whole fundus and body of the organ is 
accompanied with a feeling of numbness, which is pro- 
pagated to the internal orifice. To this numbness 
succeeds a painful stretching, which begins along the 
posterior wall of the neck, toward the base of the sa- 
crum, descends obliquely around the sides, in the 
direction of the internal orifice, and terminates at the 
OS tincse, profoundly in the vagina, where the pain is 
most severe" (1). 

In the commencement of the first stage of labor, 
the pains are slight, both as to force and duration, and 
the intervals between them are considerable. But in its 
progress, they increase in firequency, dm^ation, and inten- 
sity, until they are gradually merged in the stronger 
throes of the second stage. A satisfactory reason may, 
perhaps, be assigned for their gradual augmentation; it 
accords, at all events, with our theory of labor, and may 
be received for what it is worth. It is this : the mere 
contact of the ovum, aided by its gravity, is sufficient, 
after a longer or shorter time, to produce such a degree 
of orificial irritation as serves to awaken the parturient 
contraction of the womb. Labor being thus started, 
the pressure of the ovum against the neck, during the 
pains, increases the orificial irritation, which, in its turn, 
excites stronger contractions, and by the continuance of 

(1) Memorial de 1' Art des Accoucliemens, p. 206. 



'SHOW." 115 



this action and reaction, labor is quickened untU it 
acquires its greatest intensity. 

2. '^ The show'''' of mtrses, '' gl aires''' of French 
writers. This may commonly be regarded as a certain 
indication of labor, or, at least, of its near approach. It 
is a transparent, ropy mucus, escaping from the vagina, 
secreted chiefly by the follicles of the neck, one of 
whose offices it is to furnish this albuminous fluid to lu- 
bricate the parts, preparatory to the passage of the 
child. The immediate cause of this increased secretion 
appears to be the mitation resulting from the distention 
of the cerATLx uteri, which may exist, in a slight degree, 
several days before labor, properly so called, is estab- 
lished. In fact, sHght contractions of the fundus, for a 
week or two previously, is no unusual prelude to labor ; 
and in consequence of these, the uterus subsides in the 
abdomen, giving greater hberty in the epigastric region, 
but encroaching on the pelvis, and embarrassing the 
functions of the bladder and rectum. 

When labor has commenced, if not before, this mu- 
cous discharge is very apt to be streaked with blood, 
efiused from ruptured decidual vessels about the cervix 
uteri. Sometimes this effusion is considerable without 
amounting to hemorrhage, properly so called. If there 
is default of this secretion, the woman is said to have a 
'' dry " labor; more commonly, however, she is not, ac- 
cording to my experience, in labor at all, — this dryness 
being quite characteristic of what are called "false 
pains." 

3. Dilatation of the os uteri. At the commence- 
ment of labor, the uterine orifice may be felt as a circu- 
lar aperture, of small size, — at most barely receiving 



116 PHENOMENA OF FIRST STAGE OF LABOR. 



the point of the finger, — whose margin is commonly 
thinner in primipar^e than in women who have borne 
children. Under the influence of the uterine contrac- 
tions, its circle is gradually widened, and its margin 
rendered thinner, until it is fully expanded. Although 
the effect of every pain is some increase of its dilatation, 
it is to be observed that during the pain, the orifice is 
more contracted than just previous to it, and its margin 
feels firm and rigid. The actual, successive yielding, 
then, immediately follows each pain; and during the in- 
tervals, the OS uteri is more and more disposed to yield. 
From this we should expect what all writers have 
taken notice of, and which cannot have escaped the ob- 
servation of any one engaged in practice, viz., the 
greater rapidity of dilatation as it draws toward its 
completion, so that although it may have required many 
hours of severe suffering to dilate the orifice to the size 
of a dollar, a few more pains, nay, sometimes a single 
pain, may finish its dilatation. 

4. Formation of the memlraneous pouch. That por- 
tion of the membrane, which is denuded by the open- 
ing of the OS uteri, yielding to the pressure of the ute- 
rine contraction, is forced through the orifice, and pro- 
jects into the vagina as a tense tumor during the pains, 
but is retracted and flaccid in the interval. This is 
known by the name of the " membraneous pouch," the 
"aqueous cyst," or the "aqueous pouch," because it 
contains, of course, a portion of the waters of the ovum. 
The form of this pouch varies according to that of the 
orifice, being most frequently round and hemispherical, 
sometimes ovoidal, when the neck dilates more in one 
direction than in another. When the membranes are 



MEMBRANEOUS POUCH. 117 



unusually extensible, and contain but little water, they 
may project into the vagina, even as far as to the vulva, 
in the form of a cylindrical purse. The pouch is gen- 
erally less voluminous in vertex presentations than in 
any others, being sometimes flat and scarcely recogniza- 
ble, whereas, in less favorable presentations, as, for ex- 
ample, the nates, it forms a remarkably large projection, 
and effectually hinders us from ascertaining what part of 
the child lies above it. 

Connected with the membraneous pouch, there is a 
phenomenon, which has given rise to what I consider a 
singular mistake or delusion ; I allude to the apparent 
elevation of the presenting part of the child at the be- 
ginning of each pain, and its depression before the pain 
goes off. In view of this, Miiller declares, that " the 
uterine contractions appear to commence at the os uteri, 
to be propagated toward the fundus, and again to return 
thence toward the mouth of the uterus. By this suc- 
cession of muscular contractions, the fetus is first raised, 
and then propelled downward toward the os uteri, when 
the lips or sphincter of the latter part become thinned 
and dilated "(1). Dr. Churchill adopts this idea: " The 
pains, as I have already said," he remarks, " commence 
in the cervix, and gradually involve both the body 
and fundus; their first effect, as Wigand has ob- 
served, being to elevate, as it were, the presenting part, 
and afterward to force it down " (2). Such a mode of 

(1) Elements of Plijsiologj, translated by Dr. Balj, and ar- 
ranged by Dr. Bdl, Philadelphia, 1843, p. 849. 

(2) Theory and Practice of Midwifery, second Amer, ed., 1846, 
p. 192. 



118 PHENOMENA OF FIRST STAGE OF LABOR. 



uterine action is not more repugnant to Madame Boi- 
vin's sensible description of it, than to reason and com- 
mon sense. The truth appears to be, that as the pouch 
fills with the waters of the amnion, during the pains, it 
withdraws from the presenting part, which makes this 
appear to rise up; or, if there be actual elevation, it 
may be owing to the reflux of the waters from the 
pouch, until their equilibrium is reestablished by the 
steady persistence of the pain, when this part descends 
again. Be the matter as it will, there is surely no such 
inverted action of the uterus as the theory of Wigand 
alleges. The formation of the pouch closes the first, 
and introduces the second, stage of labor. 

Among the phenomena, which have now been enu- 
merated as belonging to the first stage of labor, dilata- 
tion of the uterine orifice is the most important, — it 
alone, indeed, constituting the end and aim of this stage. 
There has been much speculation, and not a little con- 
troversy, as to the means employed by nature to attain 
this end; and as the inquiry is interesting, on account 
of its practical bearings, I shall not shun it. It has 
been already proved (chapter on efficient cause of labor), 
that the body and neck of the uterus are antagonists 
in labor — the tendency of the contractions of the for- 
mer being to expel the ovum, while the contractions of 
the latter tend to retain it. Now, it is evident that 
were these antagonists endowed with equal strength, 
labor would be an interminable contest; but, in point 
of fact, they are unequal — the body being much thicker, 
and possessing two well-developed layers of muscular 
fibers, instead of one only, which belongs to the neck, 
the preponderance of strength is, therefore, in favor of 



MANNER IN WHICH THE OS UTERI IS OPENED. 119 



the body; but, as the battle is not to the strong, let us 
inquire how its forces operate to achieve victory, and 
open the os uteri. 

It must be remembered, then, that the gravid uterus 
at term is of an ovoidal figure, the fundus being its 
large, and the cervix its small, extremity, and that it is 
completely filled and distended by the fetus, with the 
waters surrounding and the membranes inclosing it, 
which together constitute the ovum. This ovum pos- 
sesses, of course, the same figure as the gravid uterus ; 
and is nearly, if not quite, incompressible by any force 
that is brought to bear upon it. The force of the body, 
which I shall call its propelling force, may be represent- 
ed by fines, drawn from every point of its surface, cov- 
ered by the obfique and concentric fibers, toward the 
center of the organ, — for the pressure, exerted by the 
contraction of these fibers on every point, acts in that 
direction. The force, for example, exerted at the cen- 
ter of the fiindus is in the direction toward the os uteri, 
— that, at either extremity of the transverse diameter 
of the uterus, is in a direction at right angles with the 
first, — and that, at a point midway between these, is in 
a diagonal direction. As the ovum cannot obey all 
these forces, it is moved in what is called their resulting 
direction, which, it is obvious to those in the least con- 
versant with physics, is in a straight fine from the 
center of the fundus to the os uteri, — in other words, 
in the direction of the axis of the uterus. The scat- 
tering rays of propeUing force are thus brought to a 
focus upon the os uteri, and the efficiency of this force 
is evidently increased by its concentration upon the 
point to be assailed. 



120 PHENOMENA OF FIRST STAGE OF LABOR. 



But the propulsion of the ovum against the os uteri 
is not the only effect produced by the operation of this 
force. During every parturient contraction, the ovum 
is subjected to pressure at every point of its surface, not 
excepting the inferior segment of it, in contact with the 
cervix uteri. Were this pressure everywhere equal, it 
is evident that the ovum would be condensed toward its 
center, to the extent allowed by its slight compressi- 
bihty ; and it would undergo no change of figure what- 
ever. But this pressure is not, in fact, equal — that of 
the fundus being by far the most powerful — hence, 
during every pain, the inferior segment of the ovum is 
expanded by the more forcible compression to which the 
superior segment is subjected, and its figure, together 
with that of the uterus, is altered -— it is less acumi- 
nated toward the cervix. The expansion of the inferior 
segment of the ovum distends the cervix uteri in such 
a manner as is tantamount to pulling asunder its parietes 
and stretching its vaginal orifice. I will try to illustrate 
this idea. The first effect of each uterine contraction is 
to propel the ovum toward the os uteri ; but this being 
resisted by the os, the inferior segment of the ovum 
begins to expand, and the starting point of this expan- 
sion is at the os uteri, from which it spreads in all direc- 
tions, operating as a great number of cords pulHng from 
the OS toward the circumference of the cei'vix. The 
tonic contraction assists the muscular, in this dilating 
operation, by giving permanency, in some degree, to the 
altered figure of the ovum ; for, although in the inter- 
vals of the pain the membranes are not as tense as 
during then- continuance, yet it would be contrary to 
its nature to suppose that the tonic contraction will fail 



MANNER IN WHICH THE OS UTERI IS OPENED. 121 



to preserve, in a good degree, the ground gained by the 
muscular ; and this it is, perhaps, which gives rise to the 
uneasy sensations, which, as I have stated, women often 
experience in the intervals of the pains. 

When the resistance of the cervix is considerably sub- 
dued, and the external orifice is opened to some extent, 
a portion of the membranes becomes insinuated within 
it, and the pouch thus formed contributes materially to 
complete its dilatation. The agency of this pouch has 
not, however, been properly understood by authors, and 
their erroneous appreciation of it has led to m^alpractice. 
Dr. Denman asserts that "it forms a soft pillow, which, 
at the time of every pain, acting upon the principle of a 
wedge, operates Avith increasing force according to the 
size it acquires ; in consequence of which the latter part 
of the dilatation usually proceeds with more expedition 
than the former, unless the membrane containing the 
waters be previously ruptured" (1). British writers, 
since the time of Denman, have cleaved to the wedge- 
like operation of the pouch with peculiar pertinacity. It 
is, notwithstanding, obnoxious to the very serious objec- 
tion that the membranes do not, as we have seen, enter 
the OS uteri, until the resistance of the cervix is so far 
overcome, that it is disposed to dilate, when there is no 
need of a power that acts upon the principle of a wedge. 
This dilatabihty of the os uteri results from, and is evi- 
dence of, the declining energy of contraction in the cer- 
vical fibers, which have been partially paralyzed by the 
propelling force. 

The formation of the pouch, then, is the conse- 

(1) Introduction to Midwifery, cliap. IX, sect. 6. 



122 PHENOMENA OF FIRST STAGE OF LABOR. 



quence, not the cause of the dilatation, or, at least, of 
the dilatability of the os uteri. But supposing the or- 
der to be reversed, and that the pouch is formed first, 
to be the instrument to overcome the resistance of the 
cervix, — could it procure the dilatability of the os uteri 
as efficiently and kindly as the method ordained by na- 
ture ? No one, who has made the attempt to introduce 
his hand into the uterine cavity prematurely, that is to 
say, before the os uteri is easily dilatable, will answer 
this question in the affirmative, for it is found that the 
OS uteri could sooner be lacerated than forced to open in 
this way. The reason is very obvious; the hand, act- 
ing in this manner, operates at first only on the circles 
of fibers immediately surrounding the orifice, and then 
on the next, and so on until the whole series is reached 
in detail; whereas natm^e, wiser than art, brings her 
force to bear simultaneously on the whole extent of the 
cervix. Hence, we are at no loss to understand why 
the dilatation of the os uteri proceeds so much more 
rapidly toward its completion than in the commence- 
ment. It is not, as Dr. Denman suggests, because the 
pouch " operates with increasing force according to the 
size it acquires," but because the cervix having been 
conquered, the inferior part of the ovum has only to 
tak^ possession of its orifice. 

Dr. Dewees is entitled to much credit for his satis- 
factory refutation of the doctrine against which we are 
contending; but it is to be regretted that, in his zeal to 
demolish it, he lost sight of the real utility of the mem- 
branes, both before and after the protrusion of a portion 
of them at the uterine orifice. The premature rupture 
of the membranes and discharge of the waters will not, 



MANNER IN WHICH THE OS UTERI IS OPENED. 123 



he thinks, retard labor or render it more painful, except 
this occurs under one special condition, viz., before gen- 
uine expulsive action of the uterus has commenced, 
and where uterine contractions speedily follow the ac- 
cident. If labor have commenced, no matter how 
slight may be its progress, or if the uterus be not 
" surprised into contraction " by the accidental rupture 
of the membranes, before it is " prepared for the regular 
routine of labor," dilatation will take place as rapidly 
and favorably as if notliing had happened (1). These 
assertions contradict the experience of the profession, as 
far as I know, in all ages and countries ; and I cannot, 
therefore, help suspecting that there is some fallacy in the 
observations on which they are founded. They are no 
less at variance with the explanation of the process of 
labor which I have given, as the following considerations 
will show. 

First. The integrity of the membranes, before the 
pouch is formed, is valuable, because the propelhng force 
has then a more suitable medium wherewith to act on 
the cervix than any part of the fetus would be. This 
medium is the waters inclosed by the membranes, 
which, adapting themselves to the shape and inequal- 
ities of the cervix, make more equable pressure on its 
fibers, and consequently subdue their resistance more 
equally ; whereas any part of the child, that can pre- 
sent, is not so well adapted to distend the cervix equal- 
ly, and hence while some of its fibers may be benumb- 
ed by pressure, others are not conquered, but provoked 

(1) See chapter "on tlie manner in which the os uteri is 
opened," Midwifery, p. 180, fifth edition. 



124 PHENOMENA OF FIRST STAGE OF LABOR. 



to inordinate resistance, thus retarding labor by the 
iiTegular contraction which is excited. 

Secondly. The integrity of the 'membranes, after 
the pouch is formed, is beneficial until the dilatation of 
the OS uteri is considerably advanced, if not completed; 
because the pouch, though it does not cleave like a 
wedge, opens the portals for the egress of the child, in 
the gentlest manner. Should it rupture before the ori- 
fice is prepared to allow the presenting part of the child 
to take its place, the ruder contact that ensues not un- 
frequently irritates the cervix to a renewal of its oppo- 
sition, and labor is thus protracted and rendered more 
painful. 

'Thirdly. The pouch serves, by its presence in the 
uterine orifice, the most sensitive portion of the neck, 
to sustain and enliven the propelling contractions, upon 
the principle of orificial irritation. By its agenc}^, these 
contractions are, in proper time, rendered truly expid- 
sive, and the auxiliary forces of the diaphragm and ab- 
dominal muscles called into action. When the pouch 
ruptures, the presenting part of the child takes its place, 
and keeps up the requisite grade of irritation until the 
labor is completed. That this is no fancy sketch, the 
phenomena of shoulder presentations will abundantly 
prove. In these cases, the membranes frequently pro- 
trude in the form of a long, cylindrical purse, which in- 
adequately stimulates the os uteri, and consequently the 
pains are feeble, for an unusual length of time; and 
when at length they rupture, if the shoulder is not 
ready to occupy the orifice, as often happens, there is an 
entire suspension of the pains for several hours. 

Having rejected the agency of the membranes. Dr. 



MANNER IN WHICH THE OS UTERI IS OPENED. 125 



Dewees was forced to invent some other method of ac- 
counting for the dilatation of the os uteri, which, it may 
be fairly presumed, he found to be no easy task 5 for, 
notwithstanding he devoted a whole chapter to the sub- 
ject, he reverts to it repeatedly in various parts of his 
work. He has thus made it a task not less difficult for 
his reader to gather his views, dispersed as they are, 
and not always expressed in the most perspicuous man- 
ner. Discussing the cause of labor, he inquires (p. 149), 
whether it is not "prohaUe, that the uterus possesses 
some organic power by which it effects the opening of 
the OS uteri, and which is totally indeiJendent of the me- 
chanical influence of the distended membranes; since a 
certain degTce of dilatation takes place without their 
agency ? " On the next page but one, he explains, in 
a note, his meaning rather obscurely worded in the iQ-^i^ 
by saying, that '' The circular fibers of the neck and 
mouth of the uterus relax themselves, and thus give to 
the longitudinal fibers the control ; for, by the contrac- 
tion of the latter, the uterus becomes shorter, and con- 
sequently wiU widen itself at its opening, by drawing 
the circular fibers upward. When this happens, the 
mouth of the uterus is drawn or has a tendency to be 
drawn upward, and the presenting part escapes from 
it," etc. Here he seems to be getting into the twilight 
of truth ; but in another place, discussing the nature 
of rigidity of the os uteri, he refers it to a "failure 
of the reciprocity of sympathy in the several parts con- 
cerned in labor," in consequence of which " the ordinary 
and essential changes for an easy delivery do not take 
place 5" "in other words," he says, "to employ the lan- 
guage of Mr. Hunter, the stimulus of relaxation is not 



126 PHENOMENA OF FIRST STAGE OF LABOR. 



given or is not obeyed ; " and then, in the next para- 
graph, he adds, "in the ordinary course of a healthy 
labor, the mouth of the uterus opens by some secret 
agency, or, at least, without any apparent force." 

And, now, even twilight has forsaken him, and he 
gropes in profoundest mysticism, fancying, perhaps, that 
the OS uteri is, after all, opened by some such spell as 
that which swayed the mouth of the robber's cave, in 
the Arabian Nights' Entertainments, — " Open, Sesame V 



TREATMENT OF FIRST STAGE OF LABOR. 127 



CHAPTER VIII. 
THE TREATMENT OF THE FIRST STAGE OF LABOR. 

The first is the most dilatory of all the stages of 
labor, — it being the preparation for what is to foUow, 
and preparation, in most things, usually requiring a 
longer time than execution. It may, therefore, be 
reckoned a prime duty of the accoucheur to wait pa- 
tiently, as a general rule, until this stage is naturally 
accompHshed. But is there no hmit to the patience he 
must exercise? Is there no dilatoriness on his part 
which is reprehensible? Must the first stage of labor 
be always left to take its course, unless there be some 
uncommon and palpable necessity for interference? 

These are important questions, and their solution, 
more than anything else in obstetrics, settles the 
practial complexion of each individual to whom they 
are propounded. Hear the answer of Dr. Denman- — 
" Whether a short or a long time be required for this 
purpose (the dilatation of the os uteri), it is the duty 
of the practitioner to abstain from interfering in this 
part of the process. It may sometimes be necessary 
to pretend to assist, with the intention of giving confi- 
dence to the patient, or composing her mind. But aU 
artificial interposition contributes to retard the event so 
impatiently expected, by changing the nature of the 
irritation and the action thereon depending, or does 
mischief by inflaming the parts, and rendering them 



128 TREATMENT OF FIRST STAGE. 



less disposed to dilate; in short, by occasioning either 
present disorder or future disease" (1). So spoke the 
British oracle, in the latter part of the last century; and, 
with two or three exceptions, his successors, to the 
present time, have echoed the authoritative response. 
The published lectures of one of them, who is yet liv- 
ing (2), are full of kindred advice, eloquently and 
vehemently enforced, — exhorting the pupil to abstain 
from every species of interference, unless urged by dire 
necessity, and turn where he may, almost upon every 
page, the apothegm stares him in the face, — "a med- 
dlesome midwifery is bad." The deepest impression 
which his teaching is calculated to make, is, that nature 
is particularly careful not to be at fiiult in the matter of 
childbirth, and that it is a fearful thing to do aught but 
admire her proceedings. 

I have said that one's cast as a practitioner is de- 
termined by his views of professional duty, in the man- 
agement of the first stage of labor; if he perform the 
part of an expectant in the first act of the drama, it is 
not likely that he will appear in any other character in 
the subsequent acts. Now, it is notorious that Dr. 
Denman, for example, is hesitating and indecisive in the 
advice he gives, touching the conduct of the obstetrician 
in every branch of his duties; and after most carefully 
considering his views, one can hardly determine whe- 
ther, upon the whole, he had best to do something or 
nothing. 

(1) Introduction to Midwifery, chap. IX, sec. 6. 

(2) Lectures on the Principksand Practice of Midwifery, by 
James Blundell, M. D., edited by Charks Severn, M. D. Phila- 
delphia, 1842. 



GENERAL CONSIDERATIONS. 129 



With the tenets of Dr. Denman contrast those of the 
late Professor Hamilton, of Edinburgh, who states that 
he was but a very short space of time in practice, when 
he saw reason to beheve that the management of the 
first stage had been much misunderstood by the profes- 
sion. Observing that when the natural powers alone 
are trusted to, this stage is often greatly protracted, he 
inferred, from reasoning upon the subject, that injurious 
effects must be the consequence. "He considered," to 
use his own language, "that upon the occurrence of 
every uterine contraction, there must be a certain influ- 
ence on the action of the heart and arteries, and that if 
pain and sleeplessness were continued beyond a limited 
time, there must be an exhaustion of a sensorial power. 
He concluded, therefore, that where the first stage of 
labor is not completed within a certain time, the strength 
of the patient must be proportionably lessened, the ute- 
rine action must be enfeebled, and the circulation of the 
blood must be disturbed" (1). But, finding that the 
most respectable practitioners, both British and foreign, 
deprecated all interference with the first stage of labor, 
he felt diffident in promulgating his opinions, and did not 
do so until the year 1800, when he stated as the result 
of his observation and experience, for about fifteen years, 
that " unless the first stage of labor ( supposing that 
there are regular pains ) be completed wiiliin twelve or 
fourtee^i hours fi:om its real commencement, the follow- 
ing consequences may be dreaded : 

"Firstly. That the powers of the uterus may be 

(1) Practical Observations on various Subjects relating to Mid- 
wifery. American edit., Part 1, p. 60. 

9 



130 TREATMENT OF FIRST STAGE. 



inadequate to expel the infant with safety to its life, or 
to the future health of the parent. 

" Secondly. That after the birth of the infant, the 
uterus may contract irregularly, so as to occasion the 
retention of the placenta. 

"Thirdly. That after the expulsion of the placenta, 
the contractions of the uterus may be too feeble to pre- 
vent fatal hemorrhage. And, 

" Lastly. That, supposing the patient should escape 
all those untoward circumstances, febrile or inflammatory 
affections of a most dangerous nature may ensue, from 
the previous protraction of pain and the irregular distri- 
bution of the blood." 

In view of these facts. Dr. Hamilton adopted it as a 
rule of practice, that the termination of the first stage of 
lalor should he secured within ttuelve or fourteen hours 
from its actual commencement. 

In prescribing limits to the first stage of labor, he is 
careful to guard against any mistake or abuse that might 
grow out of the restriction : there must be a continu- 
ance of regular pains for the period specified, "for it 
sometimes happens that, after regular pains have com- 
menced, the agitation of the patient, or the mismanage- 
ment of the attendants, occasions a suspension for some 
hours. If there be no injurious pressure upon the pas- 
sages during that suspension, the patient's strength is 
recruited, and the duration of the first stage is to be 
reckoned from the recurrence of the pains." And then 
again, spurious pains are to be discarded from the esti- 
mate ; these may precede the true ones for hours, or 
days, producing no tightening of the edges of the os 



GENERAL CONSIDERATIONS. 131 



uteri ; and unless this is present, labor has not really 
commenced. 

By the adoption of this rule, the author asserts con- 
fidently that " no jjcdient U7ider Ms charge, for the last 
thirty-five years, has been above twenty-four hours in la- 
hor, and, except in cases of disproportion, none so long. 

Such a result as this, — so encouraging to those 
who are expected to alleviate the sufferings, and abridge 
the anguish of the sex, and who derive unfeigned plea- 
sure from the fulfillment of thek responsible mission, — 
challenges the candid consideration of every one, who is 
qualifying himself for the practice of obstetrics. It is 
entitled to the sober second thoughts of such as are al- 
ready engaged in practice under a different creed; 
but, alas ! with how little prospect of success can they 
be appealed to, since the principles, from which this re- 
sult was obtained, are condemned as heretical by nearly 
all authors, except Professor Burns. The latter even 
abridges the period prescribed by Dr. Hamilton, within 
which the first stage of labor should be completed. 
" If," he says, " th6 pains be continuing without suspen- 
sion, for an interval of some hours, and the labor be 
going on all the time, but slowly, it is a good general 
rule to effect the dilatation of the os uteri within ten or 
twelve hours, at the farthest, from the commencement of 
regular labor " (1). In relation to the necessity of this 
he speaks thus confidently: "It is an undeniable propo- 
sition, that there is in every case a period beyond which 
it cannot be protracted without exhaustion; and it is 

(1) Principles of Midwifery, American Edition, wi*^Ji notes by 
Professor James, Vol. I, p. 417. 



132 TREATMENT OF FIRST STAGE. 



no less certain, that if we wish to avoid this exhanstion, 
which may be followed by pernicious effects^ we have 
only the choice of either suspending the action alto- 
gether for a time, or of endeavoring to render it more 
efficient, and of effecting the desired object within a 
safe period." 

The doctrine of Hamilton and Burns, on this sub- 
ject, I have ever considered sound in the main, and 
their practice worthy of imitation. It is, therefore, in- 
cumbent on me to explain the one a little more fully, 
and defend the other. The doctrine assumes that the 
uterus is incapable of continuing its parturient action 
beyond a definite period, notwithstanding its frequent 
respites, without falKng into a state of exhaustion that 
unfits it for the proper performance of its function. 
And does any one doubt the truth of this assumption ? 
If so, let him refer to any treatise on practical midwifery, 
worthy of its title, in which there is not a distinct re- 
cognition of a poiverless state of labor, — not that the 
uterus is so completely exhausted as to cease its action 
altogether, but it is so enfeebled as to be disqualified 
for efficient action, and the delay and danger, incident 
to such a state, call loudly for assistance. It is worthy 
of observation that before the uterus reaches this deplo- 
rable state, it is liable to become morbidly mitable and 
sensitive, so that it is disposed hastily to eject its con- 
tents, the instant the obstacle is removed, which pro- 
voked this morbid state. This irritable condition, as I 
may have occasion to show, is scarcely less dangerous 
than the exhaustion of which it is the precursor. 

But although it may be conceded that the uterus is 
liable to exhaustion from long-continued exertions, it 



GENERAL CONSIDERATIONS. 133 



may be denied, as in fact it has been by Dr. Church- 
hill (1), that the pains of the first stage have any such 
pernicious tendency. In his chapter on " Tedious La- 
bor," Dr. Churchhiil lays down the following proposi- 
tions: "1, When the delay is excessive, the relative 
duration of the two stages is destroyed, so that they 
bear no steady proportion to each other; thus, for in- 
stance, in a labor of sixty hours, the first stage may 
occupy fifty-nine, and the second only one, or vice versa; 
2, That the effects of a prolonged labor upon the con- 
stitution of the patient, depend upon the stage in 
which the delay occurs; and 3, That delay in the first 
stage involves very little if any danger, no matter how 
tedious it may be, but that delay in the second stage^ 
beyond a comparatively short time, is always of serious 
import. 

These deductions. Dr. Churchhiil thinks, are in- 
volved, though not distinctly enunciated, in the prac- 
tical remarks of writers on midwifery, who distinguish 
the cause of delay in the first stage from those in the 
second, as being much less dangerous : and in further 
corroboration of them, he pubhshes a tabular synopsis 
of one hundred and forty-three causes, to exhibit the 
relative duration of each stage, in labors of twenty-four 
hours and upward, in which the delay occurred in the 
first stage, and the results to mother and child. The 
table offers such cases as the following; — first stage 
34^ hours, second J hour, — first stage 41 J hours, 
second 5 hour, — first stage 5 9 1- hours, second ^ hour, — 
first stage 176 hours, second 1 hour. Notwithstanding 

(1) Theory and Practice of Midwifery, Philadelpliia, 1846. 



134 TREATMENT OF FIRST STAGE. 



the tediousness of the labors, all the mothers recovered, 
and but ten of the children were lost, one of which was 
putrid. It is plain that these statistics, supposing them 
to be accurate, are fatal to the views of Professor Ham- 
ilton ; for it would appear from them that the powers of 
the uterus are not enfeebled in the slightest degree, by 
the utmost prolongation of the first stage ; on the con- 
trary, the second stage is, notwithstanding, executed with 
remarkable facility, and without involving the least risk, 
present or prospective, to the mother; the only disad- 
vantage being the loss of a larger proportion of the 
cliildren, than in labors performed in better time. 

I was, I confess, greatly astounded when my atten- 
tion was first directed to these statistics; not because 
they militated against a favorite doctrine or theory 
(that I could have easily siirrendered at the summons 
of truth), but because if they are to be relied on, I have 
yet to learn the alphabet of practical midwifery. Ex- 
perience for more than a quarter of a century (a long 
time to be under delusion), has seemed to teach me that 
if the first stage be unusually protracted, the second is 
liable to be so too ; or where it is not correspondingly 
delayed, it is liable to be executed so precipitately as to 
endanger both mother and child, — the uterus having 
acquired the morbid irritability to which I have alluded. 
In the latter case, irregular contraction is apt to follow 
the expulsion of the infant, producing difficulty in the 
third stage. 

In rehearsing my experience, in general terms, I 
have been careful to say "liable," because there is no 
rule without exceptions, and it does sometimes happen 
that tedious first stage is followed by safe and reasona- 



GENERAL CONSIDERATIONS. 135 



ble promptitude of the second. These exceptions are 
not, however, numerous enough to account for Dr. Chur- 
chill's one hundred and forty-three cases, Avhich he sa3^s 
expressly were not culled for the occasion. How, then, 
are they to be accounted for ? I could never have an- 
swered the question, if, in turning over his pages, I 
had not stumbled on his definition of the first stage, 
which is as follows : — " extending from the commence- 
ment of labor to the passage of the head through the 
OS uteri" (p. 199). When the head has passed through 
the OS uteri, it is, I opine, near its journey's end ; for 
nothins: is more common than for the anterior edo;e of 
the OS uteri to be felt in advance of the head, a few mo- 
ments before it emerges, although the pains may have 
been decidedly expulsive, that is, the second stage ex- 
isted, for hours previously. 

The complete dilatation of the os uteri, spoken of as 
the end of the first stage, is never its obliteration, so 
that it cannot be felt and does not even require a de- 
gree of force to engage the head in it, — but such an 
opening of it as wiU allow the head to pass with no 
more resistance than the other soft parts, the vagina, 
perineum, and ^oilva, ordinarily offer, — for labor is a 
struggle throughout. Before the os uteri is dilated to 
this degree, the membranes protrude through it, and 
with sufficient dilatation of the orifice and the formation 
of the membraneous pouch, the first stage of labor 
closes, and the second is ushered in by expulsive con- 
traction, only slightly different at first from the propel- 
ling contractions of the former. 

According to my understanding of what belongs to 
the several stages of labor, then (which accords with 



136 TREATMENT OF FIRST STAGE. 



the best writers), Dr. ChurcliiU's second stage is indebt- 
ed for its remarkable brevity to bis gratuitous bestowal 
of a goodly portion of it upon the first stage, and his 
table is, therefore, valueless and proves nothing. I shall 
only add that, in tliis same chapter, he concedes the 
point in dispute when he allows, that "undoubtedly a 
prolonged first stage is a bad preparation for any acci- 
dental comphcation of the second." AVhy is it "a bad 
preparation," but because the patient is fatigued and 
worn out with unprofitable suffering, and the energy of 
the uterus is impaked ? 

Having thus endeavored to establish general princi- 
ples for our guidance, I proceed to notice the most 
common causes of delay in the first stage of labor, and 
the best means of removing them. 

1. OUiqiiity of the uterus, by which is meant a 
want of correspondence between the axis of the uterus 
and that of the superior strait. A slight degree of ob- 
liquity, forward or to one side, usually to the right, ex- 
ists in all cases, which, as it is spontaneously corrected, 
is not worthy of serious notice. But if the aberration 
of the uterine axis be so considerable as to place the os 
uteri against one of the sides of the pelvis, or the pro- 
montory of the sacrum, where it can be barely reached, 
or is beyond the reach of the finger, it becomes a cause 
of such retardation as demands the attention of the ac- 
coucheur, for the woman may suffer for hours or even 
days, if nothing be done to relieve her, and yet the os 
uteri be but little opened, and the membranes not at all 
engaged within its orifice. The laborpains have not the 
character of the genuine, but are productive of much 
suffering and distress, and even when they become of 




OBLIQUITY OF THE UTERUS. I37 



the bearing-down sort, the woman is not insphited by 
them as in natm^al labor, but is conscious of their 
worthlessness. 

We cannot be at a loss to account for the slow and 
painful progress of labor, in these cases. To awaken 
proper parturient contractions at first, and to bring 
them gradually up to the healthy standard, gradually 
increasing orificial irritation is required. When there 
is no vicious obliquity, the situation of the uterus is 
such that its axis corresponds, or nearly so, with the 
axis of the superior strait of the pelvis, and the os uteri, 
being in the route of the fetus, receives the impulses, 
impressed upon the fetus, by the uterine contractions. 
The OS uteri is, therefore, in the ivay to receive and 
communicate mitation. But if there be obliquity, the 
axis of the uterus does not correspond to the axis of the 
superior strait, which, nevertheless, must still be the 
route of the fetus, for it can be moved only in that di- 
rection. Propelled in this dkection, the fetus is made 
to bear upon a point of the uterus, more or less remote 
fi^om the OS uteri, which point becomes the most de- 
pendent part, and usurps the place of the os uteri, with- 
out any qualifications for performing its offices. 

In bad or mismanaged cases, this dependent part 
becomes greatly attenuated and inflamed,— descends 
before the child until it appears externally, and becom- 
ing gangrenous, is ruptured. 

In the treatment of obfiquity, the indication is, to 
restore the os uteri to its natural position. This may 
generally be efiected, by regulating the posture of the 
patient, enjoining her to he on the side opposite that 
toward which the fundus inchnes. If, for example, there 



138 TREATMENT OF FIRST STAGE. 



be inclination of the fundus toward the right side, she 
must be required to lie on the left, and vice versa; if 
anterior obliquity exist, she must be confined to her 
back. When the latter species of obliquity exists, in a 
great degree, a properly adjusted bandage around the 
abdomen will materially contribute toward restoring 
the uterus to its natural situation. 

Should strict attention to posture, continued for a 
reasonable time, fail to correct the obliquity, and the 
labor in the meanwhile make but tardy progress, it is 
proper to hook the os uteri hy inserting the extremity 
of the finger luithin its orifice, and draw it toward the 
the center of the pelvis, in the intervals of the pains. 
When a pain comes on, its tendency to relapse to its 
former position is to be resisted, with as much force as 
can be safely employed. If this tendency is too pow- 
erful to be resisted, the finger must yield to it ; but, as 
soon as the pain ceases, bring back the os uteri to the 
center, and again endeavor to maintain it there during 
the next pain. By cautiously and gently, but persever- 
ingly, acting thus, the os uteri will, after a succession 
of centripetal and centrifugal movements, be restored 
to its proper place, and, the parturient forces having 
been brought to bear upon it, its dilatation will be 
effected as speedily as in ordinary cases. 

The importance of obhquity of the uterus was, 
doubtless, overrated by Deventer, who regarded it as 
the most common cause of difficult and preternatural 
labors, w^hich cannot be true, as Baudelocque justly 
remarks, because such labors are rare, and obliquity is 
so common, that scarcely one woman in a hundred is 
exempt from it. It is furthermore true, as this same 



OBLIQUITY OF THE UTERUS. 139 



celebrated author asserts^ that the greatest degree of 
obhquity does not necessarily derange the mechanism 
of labor, or render it more difficult; — the uterine con- 
tractions, aided by the flexibihty of the fetus, being 
often sufficient to correct it. Baudelocque recognized 
it, however, as an obstacle to labor, of considerable 
moment, requiring sometimes the interposition of art, 
and he assisted in the manner which has just been 
recommended. He records the following case as a spe- 
cimen of many others that occurred in his practice : 
" A robust and well-formed woman, the mother of seve- 
ral children, presented herself, toward the close of 
1773, for delivery in the presence of my pupils, and 
afforded them, by her indociMty, an opportunity of 
observing the effects of obliquity and its treatment. 
The uterus was manifestly inclined forward, and to the 
right side, to such a degree, that its orifice, which was 
situated backward, could not without difficulty be dis- 
covered by the touch. The waters were evacuated, the 
pains frequent and violent, and the child presented 
well. The patient could not be persuaded to keep in a 
recumbent posture, and allow the presence of the finger, 
but would sit or stand, and, as often as she felt the 
pains, make improper efforts to aid them. The head of 
the child, after the lapse of twelve or fifteen hours, 
came down to the bottom of the pelvis, covered by the 
anterior-inferior part of the uterus. The uterine orifice 
could not be discovered upon any part of the sphere, 
presenting in this manner; but by directing the finger 
backward and upward, as high as the base of the 
sacrum, its anterior edge could be reached. The por- 
tion of the uterus pushed before the head, and covering 



140 TREATMENT OF FIRST STAGE. 



it like a hood, which could only be seen at first by 
sepai'ating the labia, became more apparent as the labor 
progressed. It was smooth, shining, tense, remarkably 
injected, displaying a fine network of vessels, and too 
sensitive to bear the slightest touch. The lower part of 
the abdomen was also threatened with inflammation, 
having become so painful as to be annoyed by the 
clothes. Notwithstanding she had been bled, fever 
was kindled, and her mind began to wander, when a 
fortunate incident caused her to become sufficiently do- 
cile to hsten to the salutary advice she had rejected for 
about forty-eight hours. Intimidated by the unexpect- 
ed presence of two officers of the law, dressed in their 
robes, she went to bed : I raised the abdomen with one 
hand, to diminish the obhquity of the uterus, while with 
two fingers of the other, having previously pushed up 
the head a httle, I hooked the anterior edge of the 
orifice, to bring it toward the center of the pelvis, where 
I held it during a few pains, and then permitting the 
w^oman to bear down with the strength she had left, 
she was delivered in the space of a quarter of an hour. 
The child did well, and the mother had a good re- 
covery" (1). 

A distinguished British teacher. Dr. WiUiam Hun- 
ter, differed altogether fi^om M. Baudelocque in his esti- 
mate of the influence of obliquity over labor, and de- 
clared that as far as he had been able to observe, " the 
mere obhquity of the uterus never occasions so difficult 
a labor, as to require any artificial arrangement to bring 
the OS uteri into a proper situation," and that "in such 

(1) L'Art des Accoucliemens, Tom. I, p. 168. 



OBLIQUITY OF THE UTERUS. 141 



cases, as in many others, art can do Kttle good, and pa- 
tience will never fail." The decision of Dr. Hunter has 
been generally acquiesced in by the writers of his own 
country, who have succeeded him, or if some have ad- 
mitted the necessity of confining the patient to a pro- 
per position, they agree in repudiating all attempts to 
restore the os uteri to its lost place. Nor are some of 
the later French writers much more deeply imbued 
with the doctrine of Baudelocque, in regard to obhquity 
of the uterus. M. Velpeau, not to mention others, 
confesses that, whereas he once faithfully labored to 
correct obliquity, an incident, which occurred in his 
practice, cominced him that he had been spending his 
strength for naught. ''One day," says he, "I was un- 
der the necessity of leading a case in charge of a pupil, 
who neglected the instructions I had given him. I re- 
turned in three hours and found the cer^dx completely 
dilated, the membranes ruptured, and the head well en- 
gaged. Since that time I have done nothing in such 
cases, and the organism has always succeeded in bring- 
ing everj^thing right " (1). I would ask M. Velpeau 
whether he thinks that the organism would be sufficient 
in such a case as that quoted fi^om Baudelocque ? 

In deliberating, however, upon the propriety of arti- 
ficial aid, in cases of obliquity of the uterus, the ability 
of nature ultimately to overcome the difficulties which 
they offer, is not to be taken into consideration. The 
primary question is, can obhquity seriously retard labor? 
and this has been answered in the affirmative, even by 
Dr. Hunter, in his commendation of patience, but less 

(1) Traite Complet de Fart des Accoucliemens, deuxieuie edit. 
Paris, 1835. ^Tom. II, p. 230. 



142 TREATMENT OF FIRST STAGE. 



equivocally by Dr. Denman and others of the same sect. A 
Obliquity ought, then, to be remedied in all cases, when ■ 
it unduly protracts the first stage of labor^ if the prin- 
ciples of Dr. Hamilton should govern our conduct. 
Labors, rendered tedious fi:om this cause, may undoubt- 
edly hobble to their end, even to the expulsion of the 
fetus in some way, — nevertheless all the mischiefs that 
grow out of delay, are justly chargeable to the obliqui- 
ty, and might have been averted had it been remedied. 
This is the true ground on which to rest the vindi- 
cation of the treatment I have recommended, and on 
this it might be safely rested, were it more hazardous 
than it really is. British writers, without exception, as 
far as my memory serves me, condemn all manipula- 
tion in these cases as useless, if not pernicious. Dr. 
Churchill, for example, declares that he does not think 
that interference with the os uteri is ever justifiable (1) ; 
and Dr. F. Ramsbotliam avows that he is "decidedly 
opposed to any forcible attempts being made to drag the 
OS uteri into a more convenient situation, lest it should 
be lacerated or bruised, or excited to inflammatory ac- 
tion, by the irritation necessarily attendant on our en- 
deavors; and I have," he adds, "at best very little 
faith in obliquity of the os uteri producing serious pro- 
traction, unless, indeed, there be present also more or 
less rigidity, or some disproportion between the pelvis 
and head " (2). Does Dr. Ramsbotham really believe 
that there is any danger of inflicting such direful inju- 
ries upon the os uteri, as are here depicted ? I can 

(1) Tlieory and Practice of Midwifery, Amer, ed., 1843, p. 237. 

(2) Process of Parturition, p. 197. 



INEFFICIENT ACTION OF THE UTERUS. 143 



hardly conceive how any one, restricted to the use of a 
single finger, could bruise and lacerate the part at such 
a rate, even were it his design to do all the mischief in 
his power. The truth is, the os uteri is made of sterner 
stuff than it has credit for, else would it be unfit for its 
post, which exposes it to the risk of contusiou and lace- 
ration, in the most natural labor that can occur. The 
utmost that can be conceded is, that aiukiuard and un- 
sMllful attempts in this kind may produce inflammation 
of the uterus, but this is chargeable to the operator, 
not to the operation, which need not cause paiu, much 
less any such serious consequences. For my own part, 
I can safely declare that no mischievous effects of any 
kind have ever resulted, in my practice, from such trac- 
tions upon the os uteri as have been recommended, and 
the testimony of Dr. Dewees is equally decisive in re- 
gard to then safety and efficacy. Nay, this eminent 
practitioner deemed them of so much importance as to 
advise the introduction of the entire hand, well lubri- 
cated, into the vagina, in order to get hold of the os 
uteri, with the finger, when it cannot be reached by a 
well-directed search in the ordinary way; and, under 
the circumstances that he has specu'ied, I should not 
hesitate to follow his advice, although I have not as yet 
had occasion to do it. 

2. Inefficient action of the uterus, — recognized by 
all writers as a very common cause of delay, in the first 
stage. For this condition of the uterus it is not easy 
to account satisfactorily; it has been ascribed to con- 
stitutional weakness, to disorder of the digestive organs, 
plethora, pecuhar temperament. Whatever may pro- 
duce it, the simple fact is, that the uterus is Dot disposed 



144 TREATMENT OF FIRST STAGE. 



to exert the force it possesses, in the most advantageous 
manner: the pains may be recurring with regularity, 
and may be sufficient to worry the patient, and exhaust 
her strength and spirits, yet they do Httle or no good. 
The parturient passage is cool and moist, the os uteri 
is not rigid; on the contrary, it is pliant and soft, but 
it is little affected by the pains, and does not dilate so 
as to give promise of being duly prepared for the pas- 
sage of the child, within a reasonable time. 

If any morbid state of the system can be reasonably 
assigned for this condition of things, it ought to be cor- 
rected: if the pulse is full and strong, blood should be 
abstracted: if the bowels are confined, they ought to be 
relieved by an enema, or a dose of castor oil. If these 
means fail, or not being indicated, are not resorted to, 
the proper remedy is, irritation of the uterine orifice ly 
means of the fimger^ for the purpose of exciting more 
efficient contractions of the organ. 

In the first place the manner of doing this must be 
explained, in order to guard against any misapprehen- 
sion or abuse of it. It is rarely necessary to employ 
more than the index finger, the extremity of which is 
to be introduced within the orifice, in the absence of 
pain, with its pulp or feeling surface turned toward the 
anterior lip of the os uteri. The patient is placed on 
her back, which is certainly the most convenient posi- 
tion for the manipulation. When a pain comes on, or 
after the lapse of the usual interval, whether there be 
pain or not, and for the purpose of exciting one, pres- 
sure is to be made with the finger, moved slowly around 
so as to bear successively on every part of the anterior 
semicircumference of the orifice. Havino; described a 



INEFFICIENT ACTION OF THE UTERUS. 145 



half circle in one direction, for example, toward the 
right side of the patient, the finger is to be moved in 
the same manner in the opposite direction, and these 
movements are to be continued during the pain, or, if 
there be no pain, for a minute or so. It is then to be 
withdrawn from the orifice, but retained in the vagina, 
or if kept within the orifice, it must rest from its work 
for a few minutes. When pain recurs, or should recur, 
the finger is to be used in the same manner, and so on, 
until the uterine contractions become stronger, and act 
with more efficiency upon the orifice, when it is to be 
withdrawn from the vagina. The invigorated contrac- 
tions may finish the dilatation of the orifice without 
any further assistance. Should they flag, however, or 
progress slowly, the finger may be reintroduced, from 
time to time, to freshen them. If the membranes are 
ruptured, and the os uteri contracts much during a 
pain, there may not be room for the finger between it 
and the presenting part of the child: in this case the 
finger must be used, as directed, in the interval of pain, 
and when contraction comes on, it must be withdrawn 
and made to press on the verge of the orifice. To pro- 
duce the requisite orificial irritation, the finger must 
press, with different degrees of force, in different cases; 
but in all cases, the pressure should be gentle at first 
and graduaUy increased, and it is never allowable to use 
such force as would be required, literally, to stretch the 
OS uteri. The mere contact of the finger is not sufficient 
to excite the os uteri ; it is, therefore, necessary to make 
pressure with it, but it must be remembered that this 
pressure is intended to stimulate, not to force open, and 
that it acts upon a vUal, not upon a mechanical, principle. 
10 



140 



TREATMENT OF FIRST STAGE. 



Speaking from abundant experience, I can truly say 
that it is equally surprising and gratifying to observe 
the prompt effects of this manipulation, in many cases 
of the kind under consideration. Not unj[requently, a 
few movements of the finger are sulficient to impart 
such energy and aim to the uterine contractions, that 
the waters begin to gather, as the phrase is, and cause 
the membranes to protrude. 

In recommending the practice of artificial irritation 
of the OS uteri, I am, of course, well aware that I stem 
the strongest current of authority that runs through ob- 
stetrics, and expose myself to the shafts of ridicule. 
No practice has met with such unqualified and almost 
universal reprobation. Instead of burdening my pages 
with a great many, I shall quote only a few, of the sen- 
tences of condemnation pronounced upon it. 

" Every man who has had occasion to use the lever, 
or other obstetric instruments, the lever especially, must 
be aware, that when he gets a bearing on the head, and 
begins to draw down upon the outlet, not unfrequently 
pains are excited. Previously, perhaps, the pains have 
been few and rare ; but when the head is drawn down, 
the irritation gives rise to a powerful action of the ute- 
rus; and hence we may enumerate, among the causes 
well fitted to excite the uterine movements, that com- 
pression and irritation of the mouth and neck of the 
uterus which may be produced by the action of the 
lever, or by means that are analogous. On this prind- 
pie it is, that some practitioners have advised us to 
press with the fingers on the mouth and neck of the 
womb, and others have recommended, that the fingers of 
the right hand, being deposited on the back of the 



INEFFICIENT ACTION OF THE UTERUS. 147 



vagina above, these fingers should be repeatedly drawn 
down over the front of the rectum, with pressure of the 
parts, so as to stimulate and excite the pains. Both 
these practices, however, I mention with a view to give 
a caution against them. I am not prepared to say that, 
under prudent management, they may never be safe and 
serviceable ; but I regard them with fear, and think it 
better to refrain. If the womb is to be stimulated at 
all on these principles, the vectis is, perhaps, the hest in- 
strument for the 2^u^pose " (1). 

"Nor must I allow the custom of irritating the 
mouth and neck of the womb with the finger, and rub- 
bing it down the back of the vagina, along the rectum, 
to pass unnoticed ; nor that still less justifiable mode 
of proceeding — the endeavor to dilate the os uteri by 
the first two fingers introduced within it ; which last 
means also has received the sanction of the deservedly 
great name of Professor Burns, as applicable to some 
states of the os uteri ; but which I do not feel myself 
warranted in mentioning except in terms of reproba- 
tion " (2). 

" I do not deny that dilatation may thus be effect- 
ed ; but I believe it to be hazardous in skillful hands, 
positively dangerous in unpracticed ones, and unneces- 
sary in all cases " (3). 

Even Dr. Dewees, with the inconsistency he was 
prone to fall into, when any point of practice really or 



(1) Blundell — Lecture on Principles and Practice of Mid- 
wifery, p. 361. 

(2) F. Ramsbotham — Process of Parturition, p. 170. 

(1) GhurchiU— Theory and Practice of Midwifery," p. 235. 



148 TREATMENT OF FIRST STAGE. 



apparently clashed with one of his favorite dogmas, con- 
demns it. Criticising the position of Professor Burns, 
that the dilatation of the os uteri ought, as a general 
rule, to be eflected in ten or twelve hours at farthest 
from the commencement of regular labor, he observes — 
" This position is followed by the necessary directions 
for the fulfillment of this intention by mechanical means; 
and though we acknowledge the mode pointed out for 
this purpose, and the conditions necessary to render 
them profitable, are as well guarded as the assumption 
of the principle will permit; yet we must declare our 
unfeigned aversion to the practice, for we are every 
way certain that it can be done with advantage in but 
very few instances, even by the skillful ; and never, 
without the risk of much mischief, by the unskillful or 
inexperienced practitioner. When the os uteri remains 
unyielding for a long time, it is an evidence that the nat- 
ural processes, which so beautifully, kindly, and safely 
effect this change, have from some cause or other been in- 
terrupted. And though mechanical force may be made 
to usurp the organic function, it nevertheless will always 
be at the expense of the health, or even the integrity 
( be this more or less ), of that portion of the uterus 
to which the force is applied. So well assured am I of 
this fact, that I never employ force to open the os uteri. 
Nor do I hold the argument, "that no mischief has 
been seen to follow this plan," of the sfightest weight; 
as we have it not in our power at the moment, to deter- 
mine satisfactorily any consequence, but the proximate 
or immediate effect of the violence ; which may be, and 
most probably is, but slight or even unappreciable at 
the instant it is committed. But can we with any cer- 



INEFFICIENT ACTION OF THE UTERUS. 149 



tainty declare, that many of the severe and dangerous 
chronic affections of the neck of the uterus, do not owe 
their origin to this cause ? " (1) 

Dr. Dewees may well be charged with inconsistency 
in displaying such aversion for the practice of artificial 
irritation of the os uteri, and expressing such ground- 
less fears as to its consequences, when, as we have just 
seen, he had no such dread of hooking it with the fin- 
ger and holding it in the center of the peMs, in cases 
of obliquity of the uterus. Now, I leave it to the 
reader to decide which of these manipulations is most 
likely to do violence to the os uteri, and plant the seeds 
of future disease, which spring so luxuriantly before the 
excited imagination of the doctor. It is very manifest 
that Dr. Dewees had no correct apprehension of the 
principle upon which the manipulation acts, and that he 
regarded the finger as a wedge cleaving its way into the 
uterus : hence, it is no wonder that he was shocked at 
the contemplation of it. 

It is equally manifest that the other writers, whom 
I have quoted, have formed their opinion of the practice. 
from the dangers incident to the grossest abuse of it — 
the hteral opening of the os uteri by the mechanical 
power of the fingers, formerly in vogue, which I depre- 
cate as much as they. In this case, as in many others, 
the abuse of what is good has discredited its use, and 
disseminated most erroneous notions concerning the capa- 
bilities of the OS uteri. Because it cannot bear the rudest 
handling and stretching, it has acquired the character of 
being remarkably dehcate, and we are forbidden to touch 

(1) Midwifery, p. 349. 



150 TREATMENT OF FIRST STAGE. 



it oftener than is absolutely necessary, in our examina- 
tion to ascertain the progress of labor. Now, while I 
would not be understood to encourage too great famil- 
iarity with the OS uteri, I am entirely convinced that it 
is not a touch-me-not, and that no harm ever did arise 
from such manipulations as I have recommended. I 
have, for many years, been in the habit of employing 
them, under the circumstances which have been pointed 
out, in a great number of cases, and no evil conse- 
quences whatever have resulted, but labor has been 
greatly assisted, and many accidents, as I am firmly per- 
suaded, have been averted, which would otherwise have 
happened from its undue protraction. My testimony, 
founded on experience, is therefore in favor of the 
safety and efficiency of the practice ; while those who 
condemn it so vehemently, do not even pretend that 
they have tested it for themselves. 

But as my single testimony, positive as it is, may 
not be deemed sufficient to settle a disputed point of so 
much importance in practice, I shall corroborate it with 
that of one of the most sober and judicious writers on 
obstetrics, Professor Burns, of Glasgow. In cases of 
tedious dilatation from premature rupture of the mem- 
branes, where the os uteri is lax and thin, or soft, he 
advises that it be gently dilated with the finger during 
a pain : " If this be done cautiously," says he, " it gives 
no additional uneasiness, while the stimulus seems to 
direct the action of the uterine fibers more efficiently 
toward the os uteri, which sometimes thus clears the 
head of the child very quickly, and the pains, which 
formerly were severe, but, in the language of the pa- 
tient, unnatural, and doing no good, become effective 



INEFFICIENT ACTIOxV OF THE UTERUS. 151 



and less severe, though more useful " (1). But he does 
not limit the practice to this condition alone, for he de- 
clares, that ''in most cases of tedious labor it is lenefi- 
dair When we connect this declaration with the gen- 
eral rule, so earnestly contended for by him, "to effect 
the dilatation of the os uteri within ten or twelve 
hours, at the farthest, from the commencement of regu- 
lar labor," there can be no doubt but that Professor 
Bums ver}^ frequently resorts to artificial irritation of 
the OS uteri. It makes, however, no great figure in his 
writings, nor has he any theory of labor to maintain, 
which increases the value of his testimony. Dr. Power 
is also a decided advocate for the practice, and gives 
several very striking cases in illustration of its efficacy; 
but his testimony will naturally be received with dis- 
trust, because it goes to support a favorite theory of his. 
I cannot, nevertheless, refi^ain fi:om citing one of his 
cases, because I have kept no record of my own; and 
cases, like examples, are more persuasive than precepts. 
" February, 1819. I was sent for to Mrs. C, in the 
habit of suffering very painful and lingering labors, and 
who had been many hours ill, under the care of a female 
midwife. I found her greatly dejected, under a high 
stat-e of febrile excitement, and the soft parts remarkabl}^ 
puffed and swollen, so that I found a difficulty in de- 
tecting the presentation, which proved the head, with 
one hand, and the umbilical cord descended before it. 
The pains were very sfight. After bleeding her freely, 
the inflammatory state of the vagina seemed diminished, 
and I succeeded in returning both the hand and the 



(1) Priociples of Midwifery, vol. I, p. 416. 



152 TREATMENT OF FIRST STAGE. 



cord. Beiug under the necessity of seeing another pa- 
tient, I directed the midwife, during my absence, to 
apply hot fomentation, with a view of ehciting uterine 
action. On my return, two hours after, I found her 
much in the same state, the action very sUght, and the 
head high up, so as to make httle pressure on the os 
uteri. I now appHed a bandage tightly round the belly, 
in hopes of pressing the child's head more firmly down- 
ward; after which I began to stimulate the os uteri it- 
self with my finger. These plans had a wonderful ef- 
fect in increasing the efficacy of the pains, and, more 
particularly, the latter; so much was my patient sensi- 
ble of its advantage, that, during the pains, she would 
not allow me to intermit it for an instant. After the 
head began to make way upon the perineum, the pres- 
sure of the finger was continued, with the same good 
effect. Toward the latter part of the labor, we experi- 
enced some interruption and delay, from violent pains 
in the left side and right thigh, which were soon re- 
lieved by friction of the parts affected. The patient 
was delivered of a large still-born child, in about four 
hours fi:om first commencing the abdominal pressure and 
stimulation of the os uteri " (1). 

I refer with some reluctance to the testimony of 
patients themselves, because, although it may serve to 
strengthen our own faith, it will not weigh much with 
the inquirer, while an opposer may sneer at it. But I 
have assisted in many lingering labors, where the par 
tients have been sensible that no progress was making, 
and in a few minutes after I had stimulated the os 

(1) Midwifery. 



INEFFICIENT ACTION OF THE UTERUS. 153 



uteri, the pains have become brisker and more effec- 
tive, — the orifice has rapidly dilated, and the child has 
been expelled with surprising promptitude; and when 
my ministry was over, the patients have spontaneously 
ascribed their dehvery to it, declaring, in parturient 
phrase, that before it commenced the pains had alto- 
gether "worked upward," but that when I began to 
assist, they "worked dovrnward." 



154 TREATMENT OF FIRST STAGE. 



CHAPTEE IX. 
TREATMENT OF THE FIIIST STAGE CONCLUDED. 

In pursuing the subject of the last chapter, I men- 
tion, 3. Impeded action of the uterus^ as no uncommon 
cause of delay of the first stage. By "impeded action" 
I mean action of the ordinary degree of force, or even 
greater than is usual in the first stage, but which is 
rendered unavailing by the cu*cumstances attending it. 
The circumstance that most fi^equently operates to im- 
pede the uterine contractions in producing their intended 
eifect, viz., opening the os uteri, is, the premature rup- 
ture of the membranes. It sometimes happens that the 
membranes are so frail as to give way, during the first 
few pains of labor, or even before there is any pain com- 
plained of; and, although the labor may not be affected 
by this occurrence, the first stage is rendered both more 
tedious and painful, in a sufficient number of cases, to 
justify Dr. Hamilton, and others, in considering it as 
untoward, especially in a first parturition. 

The OS uteri dilates more tediously and painfully, 
because the cervix is not so equally distended by the 
head or other presenting part of the child, as it is by 
the membranes with the fluid they inclose, and unless 
there be this equal distention, the propelling force is 
not transmitted to the orifice first, and then equally 
radiated to the circumference of the cervix, but is ex- 



IMPEDED ACTION OF THE UTERUS. 155 



pended upon such points of the cervix as are most 
pressed upon by the head of the child. Suppose, for 
example, the os tincse is too acuminated to allow the 
head to press upon it as firmly as it presses upon the 
outer circles of the cervical fibers, then, although these 
circles will be greatly distended during the pains, there 
will be but httle retraction of the os toward them, and 
consequently but httle tightening of the edges of the 
orifice, notwithstanding the pains may be severe. This 
unequal pressure operates, moreover, to disturb the 
equilibrium of the chculation in the neck of the uterus; 
being prevented from returning across the outer cervical 
circles, the blood is accumulated in the os tincse, and 
hence its tumidity and puffiness, noticed as of fi-equent 
occurrence by all practical writers. 

Among the causes which may seriously retard the 
first stage of labor. Dr. Hamilton mentions : "the inter- 
position of a portion of the cervix uteri between the 
head of the infant and the bones of the pelvis;" and 
the band thus caught between the head and pelvic bones 
operates, he thinks, as a cause of retardation, by pre- 
venting the contractions being extended to the os uteri. 
This state of things he ascribes to premature rupture of 
the membranes — to the entrance of a part of the child 
and cervix uteri into the peMs, previous to the com- 
mencement of labor — or to the large size of the head 
or smallness of the apertm-e of the pelvis. Dr. Gooch 
speaks of a " soft, flabby, and edematous " state of the 
OS uteri as a cause of tedious dilatation, which, he also 
says, is generally induced by an early rupture of the 
membranes, "owing to which the cervical portion of 
the uterus is compressed between the head of the child 



156 TREATMENT OF FIRST STAGE. 



and the pubes; and the return of the fluids being ob- 
structed, the OS uteri becomes thickened, and its dOata- 
tion is in consequence extremely slow " (1). 

That a band of the cervix may be thus intercepted 
between the head of the child and the pelvis of the 
mother, in cases of decided disproportion, I should not 
be warranted in denying (such appears to have been the 
fact in the fatal case recorded by Dr. Hamilton); but 
that this occurs from premature rupture of the mem- 
branes, I cannot believe, even on the authority of two 
such distinguished teachers. The grounds of my dissent 
are, 1. Such an interception is not necessary to explain 
what is observed — the unequal pressure of the head 
upon the cervix, without the counter pressure of the 
pelvic bones, being sufficient. 2. There is no particular 
reason why premature, any more than mature, rupture of 
the membranes should cause this interception, seeing, as 
has been already observed, nothing is more common than 
for the OS uteri to continue between the pubes and head 
until a short time before the egress of the latter, and yet 
the symptoms ascribed to this interception are most 
commonly observed in cases of premature rupture of the 
membranes. 

I conclude, therefore, that the ^^soft, flabby, and 
edematous " state of the os uteri is not the cause of its 
tedious dflatation, but that this morbid state and the 
accompanying tardy dilatation are effects of the same 
cause, viz., the disadvantageous manner in which the 
propelHng contractions act upon the cervix uteri, in con- 

(1) Practical Compendium of Midwifery, prepared for publi- 
cation by Greorge Skinner. Philad. : 1832: p. 173. 



II 



IMPEDED ACTION OF THE UTERUS. 157 



sequence of the premature rupture of the membranes. 
This altered state of the os uteri is not, however, always 
present, for the action of the uterus may be so impeded 
as to retard the dilatation of the cervix, without sensi- 
bly affecting its cu'culation. 

In the treatment of tedious dilatation, resulting from 
this cause, it will be proper to detract blood freely, if 
the OS uteri be hot, tender to the touch, and rigid as 
well as tumid: but the judicious employment of the 
fingers in aid of the uterine contractions is much more 
frequently indicated, and is often the only thing that 
can be done to assist the patient. The fingers are not 
to be used to excite uterine contractions (for they are 
already too strong), nor to stretch the os uteri, but to 
press upon its margin, during the pains, in order that 
their counter pressure may keep it in as firm contact 
with the head as the rest of the cervix, and the orifice 
be thus brought within the pale of the dilating influence 
of the uterine contractions. Both Hamilton and Gooch 
highly recommend this practice, but their object is to 
jmsh np the edge of the orifice over the head of the 
child; to hberate the band of the cervix, supposed to be 
incarcerated, — a condition which, if it really existed, 
could scarcely be reached by such a procedure. As 
affording a happy illustration of the difficulty we are 
considering, and its remedy, I quote the following case 
from Dr. Gooch: "I attended a lady whose former labors 
had been very quick; on my arrival I found the pcmis 
ivere strong, and though the os uteri was only dilated to 
the size of half a crown, I, like a simpleton, patted her 
on the shoulder, and told her to keep up her spirits, for 
the child would soon be born. A man must be a goose 



158 TREATMENT OF FIRST STAGE. 



under such circumstances to give such a prognosis; for 
he knows not when the labor will be over; and if his 
prognosis is not verified, he loses credit. Hour after 
hour passed, and the pains continued, but the os uteri 
was not more dilated, the laborpains became still more 
rapid and violent; she complained also of a constant 
pain near the symphisis pubis, and I feared a laceration 
of the uterus would take place. I bled her to the 
amount of xourteen ounces; she fainted; I kept her in 
an upright posture in order that the syncope might 
produce its full effect; the pains were suspended for 
about half an hour, when they returned, and her cheeks 
resumed their natural color. I examined, but found the 
bleeding had done no good. I then applied two fingers 
against the edge of the os uteri next the symphisis 
pubis, and pushed it up at the time of a pain, and kept 
it up after the pain was gone off: at the next pain I 
pressed the os uteri still higher, and repeated the same 
proceeding at about a dozen pains, when the os uteri 
shpped quite over the head of the child, and the labor 
was soon over" (1). 

4, A7id lastly/; MorMdly resisted action of the 
uterus, by which I mean inordinate contraction of all 
the fibers of the sphincter or cervix uteri, commonly 
called rigidity of the os ideri, is the most formidable 
cause of protracted dilatation, encountered in practice. 
Although referred by some to " natural toughness " of 
this part, it consists really, in most cases, in morbid 
irritability of the cervical fibers, in consequence of 
which they refuse to yield as readily as in a healthy 

(1) Loc. cit. 



MORBIDLY RESISTED ACTION OF UTERUS. 159 



state. It is always attended with more sufFering than 
labor in which no such morbid condition exists : " there 
is/' as Dr. Hamilton observes, " a feeling of wretched- 
ness which is not relieved during the intervals of the 
pains : sickness at stomach, with excessive retchings, 
are very usual symptoms — restlessness and despon- 
dency are the natural consequences." In an examina- 
tion per vaginam, it is discovered that the os uteri, be- 
sides feehng remarkably rigid and being more or less 
painful and hot, is so strongly contracted during the 
pains, that its margin is unusually tense — all which 
distinguishes between this and the case just considered. 

We may form some estimate of the strength of the 
resistance, which these fibers are capable of making, 
when inordinately excited, by observing its effects upon 
the head of the child. Every one, who has been much 
engaged in obstetrical practice, must have seen children 
born after tedious first labors, with the head prodigiously 
elongated and resembfing a sugarioaf. That the alter- 
ation of shape was owing to the difficult manner in 
which the head was squeezed through the resisting os 
uteri, and not to any want of room in the pelvis, might 
be inferred from the fact that rigidity of the os uteri 
occurs most frequently in first labors; and the correct- 
ness of the inference is proved by the same mother 
giving bkth subsequently to children, with greater facil- 
ity, and without any such deformity of the head. 

Besides acting as a barrier to the egress of the child, 
rigidity of the os uteri hinders the head fi-om executing the 
rotatory movement, essential to its easy escape through 
the inferior aperture of the pelvis, and thus perpetuates 
itself sometimes almost indefinitely, especially where its 



160 TREATMENT OF FIRST STAGE. 



treatment is not properly understood. To make this 
apparent to any one who comprehends the mechanism of 
labor, it is only necessary to observe that rigidity, 
though it may resist the passage of the head through 
the OS uteri, cannot prevent it from descending in the 
pelvis, bearing the cervix before it. Urged by the pro- 
pelling contractions of the uterus, the head does in fact 
descend to the bottom of the pelvis, and seems to be on 
the point of emerging from it : but arrived there, it can 
advance no farther, even if the os uteri were to open, 
without previously undergoing rotation. This arrest of 
the head at the inferior strait deprives the expulsive 
contractions of the means of efficiently overcoming the 
resistance of the cervix, viz., the forcible intromission of 
the head into its orifice, and consequently it is enabled 
to hold out so much the longer, in the resistance which 
it offers. 

The condition above described, viz., the head de- 
scended low in the pelvis, and held by the cervix uteri 
as it were in a sling, is, as it seems to me, the ultimate 
effect of rigidity of the os uteri, though Dr. Dewees 
does not so consider it, while he allows that it has all 
the effects of that condition. The descent of the ante- 
rior portion of the cervix before the head may, doubt- 
less, be produced by causes unconnected with rigidity, 
such as obliquity of the uterus, for example; but rigid- 
ity, when obstinate, necessarily produces it, if the con- 
tractions of the uterus become powerfully expulsive. It 
is not a little singular, by the by, that Dr. Dewees 
should not have known that any writer has noticed this 
cause of tedious labor, when it was as familiar to Smel- 
lie as to him, who recommends, also, precisely the same 



MORBIDLY RESISTED ACTION OF UTERUS. 161 



management of it (1). Dr. Smellie, moreover, relates 
cases produced by both of the causes above mentioned, 
rigidity and obHquity. 

With regard to the treatment of rigidity of the os 
uteri, it must be observed that it should be vigorously 
applied, at as early a period as possible, for the affection 
is apt to gather strength by continuance. Pmctitioners 
of the cast of those who attended upon Job in his afflic- 
tions, sadly abuse the misplaced confidence of their 
patients, upon occasions such as these. Whatever is 
to be done must be done quickly, and with unwearied 
diligence,^until the patient is rescued from suffering and 
danger. A meddlesome midwifery is bad, hit a shilly- 
shally midwifery is worse. 

The first and most successful remedy is bloodletting, 
which should be so copious as to make a decided im- 
pression on the circulatory system. " As much blood 
should be abstracted by one venesection," says Dr. 
Hamilton, " as would be taken from a patient of a simi- 
lar constitution, if she were laboring under an acute in- 
flammatory disease." Bloodletting appears to diminish 
the morbid resistance of the cervical fibers, without im- 
pairing the healthy propulsion of those of the superior 
portion of the uterus. Should venesection disappoint 
the expectations of the practitioner, the question will 
arise as to the propriety of its repetition. It is a sound 
principle in obstetric practice, though lamentabty disre- 
garded by some, to be as economical as possible in the 
shedding of blood, lest, in the progress of the labor, the 
further unavoidable loss of it should sink the patient 



(1) Cases in Midwifery, Collection XVII. 
11 



102 TREATMENT OF FIRST STAGE. 



below the point of recovery. It is therefore best, as a 
general rule, to prove at once the power of the remedy 
by bleeding from a large orifice — in order that the de- 
su'ed effect may be produced, with as little sanguineous 
loss as possible — and to resort to other means in the 
event of its failure. 

Among these, opium, in the form of an enema, de- 
servedly stands high. Admini>.tered with due attention 
to the ch^cumstances that should govern its use, it 
greatly soothes the sufferings of the patient, and pro- 
motes the dilatation of the os uteri. Dr. Hamilton's 
practice in this particular may be safely imitated : '' If 
strong and frequent pains, continued for six or eight 
hours, do not decidedly promote dilatation, the opiate 
enema should be had recourse to, and it will seldom dis- 
appoint the expectations of the practitioner. But if the 
first stage (with strong and frequent pains) be allowed 
to go on for twelve hours or upward, without having 
completed the dilatation of the os uteri, there is the risk 
that the opiate will so far interfere with the progress of 
the labor, that instrumental dehvery shall become ne- 
cessary" (1). 

Tartarized antimony is another remedy which may 
be tried, when bloodletting fails, and the opiate enema 
is judged to be improper, or has been tried in vain. 
This medicine is very highly commended by Dr. Every 
Kennedy, of Dublin, and it is mentioned on his author- 
ity more than from my own experience of it. In a val- 
uable paper, contributed by this distinguished gentleman 
to the American Journal of the Medical Sciences, for 

(1) Op. Cit, 



MORBIDLY RESISTED ACTION OF UTERUS. 163 



February, 1836, entitled " Observations on the use of 
Tartar Emetic in Obstetric Practice'' the advantages of 
tartar emetic oyer blood letting are thus set forth : " It 
is an agent by which the system can be with safety 
brought into a much greater degree of temporary de- 
pression ; between which state and relaxation of the con- 
tractile tissues, a marked connection holds, if they do 
not absolutely stand in the relation of cause and effect. 
The principal recommendation, however, to tartar eme- 
tic in these cases is, that in its use, the power of regu- 
lating the necessary degree of lowering the system, 
exists completely in the hands of the practitioner, as he 
has only to increase or diminish, or suspend the dose, in 
order to produce the effect he wishes ; and, when the 
necessary effect is produced, the withdrawal of the med- 
icine leaves the vital energies but little impaired." He 
gives the medicine in conjunction with small doses of lau- 
danum ; five or six grains of the tartrate, dissolved in 
eight ounces of water, with the addition of twenty drops 
of laudanum and a small quantity of syrup, make a 
mixture of which one, two, or more tablespoonsM may 
be given at intervals of fi:om fifteen minutes to two, 
thi'ee, or four hours, according to the effect it produces, 
and the necessity that exists for bringing the patient 
speedily or otherwise under its influence. "Some- 
times," Dr. Kennedy remarks, " it is necessary to cause 
fi'ee vomiting in the first instance, or the ordinary doses 
produce no nauseating effect; in such cases the lauda- 
num is better withheld, but may be added afterward if 
necessary. In other cases, the medicine acts too vio- 
lently as an emetic or produces purging ; here increas- 
ing the quantity of the laudanum, and diminishing the 



164 TREATMENT OF FIRST STAGE. 



doses, or allowing a longer interval to intervene between 
the doses, will be necessary." 

The extract of belladonna, made into an ointment (1), 
has been applied to the os uteri with good effect in a 
number of cases. It was introduced into the practice 
of the Paris Maternite, I believe, by the celebrated M. 
Chaussier, and since that time has been prescribed by 
most of the French obstetricians. It is necessary to 
use it with caution, as it is liable to produce head symp- 
toms and depression of the pulse; and in one case, 
mentioned by Dr. Kennedy, in the paper just quoted, 
insensibility and stertor were induced by it. 

The stramonium is a kindred remedy, which may be 
tried under the same circumstances. More than twenty 
years ago, before I was aware that belladonna had been 
recommended or used by any one in the case under 
consideration, I was led to make trial of the stramonium 
in a very obstinate case of rigidity of the os uteri. The 
case occurred in the country; having exhausted the 
usual resources to no purpose, and observing the stra- 
monium to grow in great abundance about the premises, 
it struck me that it might possibly affect the os uteri in 
the same manner that it does the pupil of the eye. A 
strong ointment was accordingly prepared from the 
leaves of the plant, and ffeely applied to the os uteri 
with the effect of rendering it less rigid and materially 
promoting its dilatation. Since that period I have oc- 
casionally used the stramonium and belladonna, but they 
have failed, oftener than they have succeeded, in pro- 
curing any marked relaxation of the os uteri. One or 



(1) Ex. belladon. 3ij., Aquae fluv. oij., Adip. Suill. 3j. 



II 




MORBIDLY RESISTED ACTION OF UTERUS. 165 



le other should, however, be tried when the means 
precedently recommended do not succeed. 

Tepid baths and demi baths have been much extol- 
led by French writers ; but in Great Britain and in this 
country they are hardly ever used. It is probable they 
have been shghted by us, or too hastily condemned. M. 
Capuron, in particular, speaks in terms of most decided 
commendation of them: "We have," says he, "derived 
great advantage from them under many circumstances, 
and prefer them to all other means, when it is necessary 
to relax the vulva, vagina, or even the os uteri." 

Lastlv. Should all the means above recommended 
fail, or but partially succeed, in overcoming the rigidity 
of the OS uteri, and the cervix descend in advance of the 
head of the child, it is necessary to raise and suiyport the 
OS uteri. As this is a measure of considerable impor- 
tance, I shall endeavor to explain how it is to be prac- 
ticed. The index finger is to be applied just underneath 
the anterior lip of the os uteri, and with its edge or 
palmar surface pressure is to be made, in the interval of 
the pains, so as to push up the os uteri as high as possi- 
ble, or the extremities of two or three of the fingers may 
he used in the same way. When a pain comes on, the 
tendency to descent is to be resisted, unless this be so 
strong as to require more force than it would be prudent 
to employ: in that case, the finger or fingers must gra- 
dually relax its counter pressure and allow the descent 
to take place. But as soon as the pain goes off, the os 
uteri is to be pushed up again, and its descent is again 
to be resisted during the next pain. In this manner, 
acting with gentleness and caution, but, at the same 
time, with firmness and perseverance, the os uteri must 



166 TREATMENT OF FIRST STAGE. 



be supported until it is sufficiently dilated to allow the 
head to execute its rotatory movementSj and emerge 
from under the symphisis pubis. 

The principle upon which this maneuver acts does 
not appear to have been well understood^ even by those 
who have practiced it. The support given to the os 
uteri prevents it from prolapsing, to be hacked, if the 
expression will be allowed, by the floor of the pelvis, and 
places it in a position that will permit a portion of the 
head to become insinuated within it during a pain. 
The finger is not used to stretch the os uteri, as many 
writers direct, but to hold it up that it may be dilated 
by the head, which can then be pushed, by the uterine 
contractions, lower than the level at which the os uteri 
is held. The head dilates the os uteri far better than 
the finger could, because it acts upon the whole extent 
of the cervix, whereas the finger could act only on the 
circle of the os uteri. 

Dr. Hamilton describes a modification of cervical re- 
sistance, consisting in what he calls "an undeveloped, 
band of the cervix uteri." This cause of protracted la- 
bor is discovered by the edges of the os uteri swelling 
during the pains, as if distended with air, and becoming 
relaxed in the intervals of the pains, and, notwithstand- 
ing strong labor throes, neither, the membranes nor the 
child are brought in contact with them. "If," says he, 
" during the interval of the pains, the finger be carried 
up within the os uteri, the stricture of the cervix will 
be distinctly perceived." The resistance, offered by 
this contracted band of fibers, is capable of greatly pro- 
tracting labor, — Dr. Hamilton says for above thirty 
hours, — and is productive of much suffering, with febrile 



MORBIDLY RESISTED ACTION OF UTERUS. 167 



excitement, nausea, and occasional tremors, resembling 
convulsions. I attended a female in two successive la- 
bors, in both of which this cause of difficulty was dis- 
tinctly detected. She had borne a number of children 
before she became my patient, and it is probable that 
the same condition existed in all her labors, for they 
were tedious and attended with alarming s}T2iptoms, par- 
ticularly with hemorrhage immediately folloAving the 
birth of the child. 

Dr. Hamilton's treatment of this obstacle consists 
in, "/r5^, venesection, if the patient's health will per- 
mit; secondly, the administration of an opiate enema; 
thirdly, half an hour after the opiate, pressure on the re- 
sisting band of the uterus with the point of the finger 
during each successive pain. The finger is to be carried 
above the strictm^e, and the pressure is to be made fi^om 
within outward." The latter means alone promptly re- 
lieved it in both instances, in the female whose case I 
have mentioned. 



168 COMMON PHENOMENA OF SECOND STAGE. 



CHAPTER X. 

COMMON PHENOMENA OF THE SECOND STAGE OF 

LABOR. 

The phenomena of the second stage of labor are 
more numerous and diversified than in the first stage, 
because the manner in which the fetus is transmitted 
through the pelvis must be varied according to the cir- 
cumstances of its presentation and position. The phe- 
nomena connected with these circumstances are strictly 
mechanical in their nature, and constitute what is com- 
monly called the mechanism of labor, — an extensive 
subject, and one of which none can be ignorant and yet 
fit to practice midwifery. 

In considering these phenomena, I shall divide them 
into the common and special; the common phenomena 
being such as belong to all labors, irrespective of the sit- 
uation of the fetus in utero, — the special, such as belong 
to, and grow out of, the different presentations and 
positions. 

The common phenomena of the second stage will be 
the subject of the present chapter. These are, the rup- 
ture of the membranes, and the ejectment of the fetus. 

1. Rupture of the memhranes. The more vigorous 
contractions of the uterus, excited by the presence of the 
membranous pouch within the circle of the dilated ori- 



I 



RUPTURE OF THE MEMBRANES. 169 



fice, soon ruptures the membranes composing the pouch, 
which are no longer supported by the uterus. 

The rupture takes place during the acme of a pain, 
and with an audible noise, if the pouch contains much 
water; otherwise without the observation of the pa- 
tient or of those about her. A more or less consider- 
able discharge of liquor aumii, according as the pouch is 
prominent or flat, immediately follows the rupture, but 
this is soon arrested by the presenting part of the child 
being pressed against the orifice. As the pain goes oiF, 
the discharge is resumed, but ceases again when the 
pain entnely subsides. Duriug the subsequent pains, a 
small portion of liquor amnii escapes at their commence- 
ment and decline, being arrested during thek acme, until 
the presenting part occupies the orifice, when its further 
discharge is prevented, and thus a remnant of it is re- 
tained. 

The retention of a portion of the liquor amnii until 
the fetus is expelled, serves to maintain more efficient 
contractions of the uterus, and shields the child from 
the dangerous compression to which it would be exposed, 
were the uterine parietes in direct contact with the sur- 
face of its body. Some explanation of this proposition 
may be desirable. 

In proportion as the liquor amnii escapes, the cavity 
of the uterus is diminished in size, by the tonic con- 
traction of its parietes, w^hich constantly, in a healthy 
state, tightly embrace the uterine contents. The fibers 
of the uterus are necessarily shortened by this process, 
and like all other muscular fibers, their power of con- 
traction diminishes in proportion as they are shortened. 



170 COMMON PHENOMENA OF SECOND STAGE. 



The actual force which these fibers are capable of ex- 
erting is, therefore, greater in consequence of a portion 
of the amniotic fluid being retained. But this is not all. 
Were the whole of this fluid evacuated, the uterine pa- 
rietes would close in upon the fetus and become molded 
to the inequalities of its body, and thus the equilibri- 
um of the parturient force would be broken, for the 
fibers not being all equally shortened; the contractile 
power of all is not equally diminished. The remnant of 
fluid serves to keep up uniform distention of the uterus, 
and preserves that equability of action among its expul- 
sive fibers, which renders their joint force most effec- 
tive. 

2. Ejectment of the Fetus. The pains of the second 
stage are, it has been already stated, stronger than those 
of the first ; they have, moreover, a peculiar character 
or expression, and are described as hearing down or ex- 
pulsive^ in distinction from the cutting or grinding pains 
of the first stage. They are not unfrequently suspen- 
ded, for a short time after the rupture of the membranes, 
until the tonic contraction brings the uterine walls in 
close contact with the ovum, and then they return with 
augmented force. We are not to imagine that the ute- 
rus is really capable of acting with greater force after 
the rupture of the membranes than before, as is com- 
monly intimated by authors, for it is in fact less capable, 
as I have just shown. The only exception to this (if 
indeed there be any) is where the uteius is so enor- 
mously distended with liquor amnii that its fibers are 
partially paralyzed by their extreme extension, but even 
then the apparent proof of their disability, viz ; the 
coming on of brisker action after the artificial e vacua- 



EJECTMENT OF THE FETUS. 171 



tion of the liquor amnii, may be otherwise explained. 
Whether the membranes be ruptured spontaneously or 
artificially, and whether much or httle hquor amnii be 
discharged, the more powerful stimulation of the os uteri, 
resulting from the direct approach and entrance of the 
head or other presenting part of the child, is the cause 
of the more forcible parturient contractions. 

Under the influence of these expulsive contractions, 
the presenting part of the fetus engages in the uterine 
orifice, which is now much more widely dilated than 
before, and is sometimes slightly lacerated at one of its 
sides, most usually the left, in consequence of the 
greater fi-equency of right obliquity of the uterus. 

The vagina receives this presenting part, as it is 
protruded through the os uteri, and is so distended, in 
all directions, as to have its rugse effaced. As it en- 
gages in the vagina, the fetus enters, of course, the 
pelvic excavation, and the os uteri, pressed against the 
walls of the vagina, may not be perceptible when this 
canal is fully occupied. But it must not be forgotten 
that the presenting part of the child may be deeply en- 
gaged in the excavation, and yet be contained entirely 
in the uterus, — the os uteri advancing before it, — and 
this is, according to my observation, a very common 
case. The vulva (meaning the genital fissure and its 
appurtenances) is next reached by the presenting part, 
and begins to be distended. The perineum loses its 
thickness and becomes more and more prominent ; the 
genital fissure is carried forward in the du^ection of the 
axis of the inferior strait, its opening appearing small in 
comparison with the large tumor of the perineum, while 
the anus is dilated; the labia are unfolded, and the 



172 COMMON PHENOMENA OF SECOND STAGE. 



clitoris, vestibule, and meatus urinarius are pushed 
before the pubic arch. In this distended state, the 
fourchette, as M. Duges remarks, is found three or four 
inches from the margin of the anus, and five and a half 
inches from the point of the os coccygis, instead of being, 
as ordinarOy, about fifteen lines from the former and 
three inches from the latter. The pains at this time are 
rending or tearing^ described by the French writers as 
conqitassantes, and irresistible requisition is now made 
upon the diaphragm and abdominal muscles; the patient 
is tormented with tenesmus, frequently the contents of 
the rectum are evacuated ; and cramps of the muscles 
of the lower extremities are excited by the compression 
of the nerves passing to them through the pelvis. 

The vulva is finally opened to a sufficient extent to 
allow the child to pass, not, however, without a slight 
laceration involving the fourchette in most first labors ; 
in such cases, also, greater resistance is made to its open- 
ing by the perineum, which suffers itself to be greatly 
distended during the pains, giving promise of a speedy 
termination of the labor, but reacts as soon as the pains 
go off, and pushes back the child. This bandying may 
last for some hours (as I know to my cost), but the pe- 
rineum becoming tired at last, allows the presenting 
part to pass, and this is usually soon followed by the 
remainder. 

Such is a rapid sketch of the more palpable common 
phenomena of the second stage of labor, which any one 
may easily observe for himself: but besides these, there 
are others of a more recondite nature, which do not the 
less deserve the study of the acoucheur because they 
are concealed from his superficial examination ; on the 



CHANGES OF THE UTERINE CIRCULATION. 173 



contraiy, tliej must be acknowledged to be of the ut- 
most practical importance. I allude to tbe changes 
which the ckculation of the blood in the uterus under- 
goes during the progress of labor. These changes are 
not, indeed, peculiar to the second stage, being observa- 
ble in the first also ; but as they are more considerable 
in the second stage, and are then alone capable of be- 
coming mischievous, this is their proper collocation. 

The ch'culation of the blood, in all muscular parts, is 
necessarily affected by the condition of the muscular 
tissue composing them. While this is in a state of re- 
pose, the arteries penetrating it are freely permeated 
by blood, which is not returned by the veins, at a more 
rapid rate than that which regulates the balance be- 
tween these two orders of vessels, in other parts of the 
system. But when the muscular tissue is in a state of 
contraction, it is condensed, — its molecules are approxi- 
mated, and it becomes harder and more resisting than 
it was while in a state of relaxation. The cahber of its 
bloodvessels is necessarily diminished, during the con- 
tinuance of its condensation, and an impediment is of- 
fered to the flow of blood into it through the arteries, 
while the exit, through the veins, of ^^hat was circula- 
ting in it, at the moment of condensation, is hastened. 
This is familiarly exemphfied by what occurs, every 
day, in the operation of venesection. The flow of blood 
can be augmented at pleasure, by dh-ecting the \. atient 
to vigorously contract the muscles of the arm, by 
grasping a cane. The accelerated flow of bluod Irom 
the orifice is, doubtless, to be ascribed partly to the aid 
received by the venous circulation fi'om muscular ac- 
tion; but it is caused chiefly by the streams of blood 



174 COMMON PHENOMENA OF SECOND STAGE. 



that are pressed out of the muscles, swelled by those 
which are turned toward the cutaneous veins, because 
they are debarred from entering the muscles. These 
effects of muscular contraction will be more considera- 
ble, and may amount to a total suspension of the circu- 
lation, if the muscular fibers are so interwoven with 
each other as to constitute a dense network, through 
whose interstices the capillaries are distributed, while 
these fibers are so arranged as to form circles around 
the larger branches. 

Now, such precisely is the texture of the muscular 
coat of the uterus, and such the arrangement of its 
fibers. We are, therefore, prepared to suspect that its 
contraction must exert a powerful control over the cir- 
culation of the vessels distributed through it, and this 
suspicion is strengthened by observing the impotency of 
all remedial means, in some cases of uterine hemorrhage, 
in an advanced stage of gestation, unless uterine con- 
traction come to their aid. It is furthermore observa- 
ble, in such cases, that the torrent of blood is arrested 
during the contractions of the uterus, but resumes its 
course in the intervals of relaxation. 

Such observations as these have been deemed, by 
judicious writers, sufficient to establish the fact, that the 
uterine circulation is suspended or greatly impeded du- 
ring the pains of labor. But as this is a point of no lit- 
tle importance, as well on account of its physiological as 
its practical bearings, it may not be amiss to corrobo- 
rate it by other evidence. This is abundantly furnished 
by obstetric auscultation. The circulation of the blood 
through the enlarged vessels of the gravid uterus is 
attended with a murmur, resembhng the sound of a bel- 



CHANGES OF THE UTERINE CIRCULATION. 175 



lowSj and called hence, by the French writers, hruit de 
souffle, M. Kergaradec, its discoverer (1), was of opin- 
ion that it is heard exclusively in that portion of the 
uterus to which the placenta is attached, and that it is 
produced by the circulation of the blood through the 
cells and tubes of the placenta. M. De Lens, who en- 
tered upon the investigation of this newly-discovered 
phenomenon of pregnancy, as soon as Kergaradec opened 
the way, adopting the idea of the latter as to its cause, 
proposed (2) calling it the placental muffle. Both Ker- 
garadec and De Lens concluded that it is emitted by 
the maternal uterine circulation, because they constantly 
observed its synchronousness with the pulse of the mo- 
ther. Many subsequent writers admit, also, its con- 
nection with the ckculation of the blood through the 
vessels of the uterus, while they deny that it is con- 
fined to that part of the organ to which the placenta 
is attached. They propose, therefore, to call it the ute- 
rine souffle or murmur. But M. Bouillaud and a few 
others contend that it is altogether extraneous to the 
uterus, being caused by the pressure of this organ, en- 
larged by gravidity, upon the iliac arteries and aorta, 
and prefer hence to call it abdominal souffle. 

M. Cazeaux, finally, attempts to reconcile these dis- 
crepancies, by alleging that two distinct modifications of 
this soufile may be heard, in examining the abdomen of 
pregnant women; — the one intermittent^ and the other, 

(1) Memoire sur 1' Auscultation appliquee a 1' Etude de la 
G-rossesse — read before tlie Royal Academy of Medicine, Decem- 
ber 1821, by J. A. Lejumeau Kergaradec, Paris, 1822. 

(2) Appendix to M. Kergaradec's Memoir. 



176 COMMON PHENOMENA OF SECOND STAGE. 



rcmiUent; — the former produced by the pressure of the 
gravid uterus upon the aorta and ihac arteries, and the 
latter by the united sounds of all the arteries distribu- 
ted through the uterine parietes. The intermittent 
souffle, he observes, is nearly always heard in the infe- 
rior lateral regions, right or left of the abdomen, — the 
remittent, which resembles the noise of a child's top 
( hniit de diable), is perceived at the superior part of 
the abdomen, in front or upon its sides. 

However this may be, there can be no reasonable 
doubt that the souffle, which is usually and most read- 
ily heard, on applying the ear to the abdomen, in ad- 
vanced pregnancy and during labor, is really produced 
by the uterine circulation. Although my own limited 
observation inclines me to the belief that it is emitted 
from the most highly vascular portion of the uterus, 
corresponding to the insertion of the placenta, yet, to 
avoid the use of terms, which imply certainty where 
there is still doubt, I shall denominate it the uterine, in- 
stead of the placental, souffle or murmur. 

K the emission of this murmur from the uterus is 
caused by the more abundant and accelerated flow of 
blood through its tissues, the faintness or extinction of 
it wall prove conclusively that the vascular currents are 
retarded or arrested in their course. Such faintness of 
the uterine murmur, gradually increasing until it can no 
longer be heard, is to be observed during every contrac- 
tion of the womb, from the commencement to the close 
of labor. In proof of this statement, I offer the follow- 
ing testimony of Dr. Hohl, as quoted by Dr. Rigby (1). 



(1) Midwifery, p. 159. 



m 



CHANGES OF THE UTERINE CIRCULATION. 177 



" The moment a pain begins, and even before the pa- 
tient herself is aware of it, we hear a sudden, short, 
rushing sound, which appears to proceed from the Hquor 
amnii, and to be partly produced by the movement of 
the child, which seems to anticipate the coming on of 
the contraction: nearly at the same moment all the tones 
of the uterine pulsations become stronger : other tones, 
which have not been heard before, and which are of a 
piping, resonant character, now become audible, and 
seem to vibrate through the stethoscope, like the sound 
of a string which has been struck and drawn tighter 
while in the act of vibrating. The whole tone of the 
uterine circulation rises in point of pitch. Shortly after 
this, viz., as the pain becomes stronger and more gen- 
eral, the uterine sound seems as it were to become more 
and more distant, until at length it becomes very dull, 
or altogether inaudible. But as soon as the pain has 
reached its hight and graduall y declines, the sound is 
again heard as full as at the beginning of the pain, and 
resumes its former tone, which in the intervals between 
the pains is as it was during pregnancy, except some- 
what louder." 

We have next to inquire into the effects of this in- 
terruption of the uterine circulation upon the fetus. 
To comprehend these, we have only to recur to the na- 
ture of the vital connection subsisting between the fetus 
and mother. We have seen, when studying the " ap- 
purtenances of the fetus," that a function equivalent to 
respiration is performed for the fetus in the placenta, for 
its blood is arterialized by its proximity, in the umbili- 
cal capillaries, to the blood of the mother flowing 
through the maternal portion of the placenta. Hence, 
12 



178 COMMON PHENOMENA OF SECOND STAGE. 



it may be inferred^ that if the intromission of fresh arte- 
rial maternal blood into the placental cells be inter- 
rupted, fetal respiration must be suspended, and that 
this interruption cannot, therefore, be borne by the fetus 
any longer than a breathing animal can bear the sus- 
pension of its respiration. Such an interruption occurs 
during at least the greatest intensity of every labor- 
pain. It must, however, be observed, that the distur- 
bance of the uterine circulation is more considerable in 
the second than in the first stage of labor, because the 
parturient contractions are the more forcible and of lon- 
ger duration, and, a portion of the liquor amnii having 
escaped, the uterus is reduced in size by its tonic con- 
traction, which permanently diminishes the caliber of 
the vessels. We ought not, therefore, to be surprised at 
the death of the fetus, if the second stage of labor be 
protracted by any obstacle, requiring unusually power- 
ful efforts on the part of the uterus to overcome it. In 
such cases, not only is there extraordinary resistance to 
the entrance of the blood of the mother into the pla- 
cental ceUs, but these cells are probably flattened or ef- 
faced, as Baudelocque suggests (1), by the compression 

(1) On this whole subject, consult his admirable section. Des 
Changemens que produit le travail de V Accouchemens dans la circu- 
lation qui se fait reciproquement de la mere a Penfani, dc. VArt 
des Accouchemens, Tom. l,p. 226. 

As the title of this section declares, Baudelocque entertained 
the notion that there is a reciprocal interchange of blood between 
the fetus and mother, through the uterine sinuses, which differ, as 
he supposed, from both arteries and veins. They are, according to 
him, a species of reservoirs, into which the uterine and umbilical 
arteries pour blood, and from which the veins of the same name 



CHAxVGES OF THE UTERINE CIRCULATION. 17 9 



to which the placenta is subjected between the walls of 
the uterus and the child's body. Nay, the umbilical 
cord is liable to suffer from this compression, and thus 
even the imperfect arterialization of the blood, which 
the placenta is capable of performing, may be inter- 
cepted. 



take it, the one, to convey fetal blood into the system of the 
mother — the other, to convey maternal blood to the fetus. 

But although the proofs of this doctrine (which he does not 
adduce in his immortal work) appeared very conclusive to him, 
there does not seem to be any foundation for it. This error does 
not, however, affect the justness of his views in regard to the in- 
fluence of labor over the maternal and fetal circulation of the 
blood. 



180 COMMON TREATMENT OF SECOND STAGE. 



CHAPTER XI 

COMMON TREATMENT OF THE SECOND STAGE OF 

LABOR. 

The conduct of the second stage to a favorable issue 
imposes certain duties on the accoucheur, which he is 
not justifiable in neglecting in any case, although it be 
true that in a large majority of cases, no harm whatever 
would result from his inattention. Experience having 
taught us, for example, that women are least obnoxious 
to dangerous accidents, when the second stage pursues 
a certain course, it is our duty to secure, as far as possi- 
ble, this most favorable course, in all cases, notwith- 
standing the possibility, or even probability, that no 
mischievous consequences would arise from its being al- 
lowed to deviate in the case under our management. 

The accident to which a parturient woman is most 
exposed, at the close of the second stage, is uterine 
hemorrhage ; and we know that this is not unfrequently 
caused by the too rapid progress of the second stage, — 
the expulsion of the child immediately following the 
rupture of the membranes. Under such circumstances, 
the tonic contraction has not time to perform its office ; 
it is, indeed, paralyzed by the sudden emptying of the 
uterus, and the organ is consequently left in an entirely 
flaccid condition. Should the placenta be detached, in 
whole or in part, by the muscular contraction that ex- 
pelled the fetus, it is plain that blood must be poured 



CONDUCT OF IT. 181 



out from the open months of the uterine arteries and 
veins, where it was lately attached. And there is never 
more risk of this perilously sudden expulsion of the 
child, than where the first stage has been protracted, 
and the uterus has acquired the morbid irritability, of 
which I have spoken in a former chapter; nor under any 
other circumstances is uterine hemorrhage so much to 
be dreaded. As an instructive illustration of the danger 
attendant on the ejectment of the child following too 
closely upon the discharge of the waters, I will give the 
substance of a case recorded by Madame Lachapelle : 
A woman, aged thirty-two years, habitually healthy, and 
the mother of several children, came to the hospital at 
eight o'clock in the morning, having had laborpains for 
four hours. The os uteri was found dilated to the ex- 
tent of fifteen lines, and the membraneous pouch was 
tense. Dilatation progressed slowly, the membranes 
descending to the vulva, although the head of the 
child continued at the superior strait. The mem- 
branes finally giving way; a very large quantity of 
liquor amnii was discharged ; the head suddenly clear- 
ed the orifice and instantly escaped through the vulva. 
The placenta was expelled with equal rapidity, much 
water following. The uterus remained contracted but 
for a moment ; complete inertia succeeding, hemorrhage 
ensued which could not be arrested by cold, or by the 
injection of vinegar into the uterus ; the introduction 
of the hand and the tampon were equally unavailing, nor 
could the prodigal exhibition of stimulants, such as 
ether, wine, etc., prevent a fatal syncope, preceded by 
convulsive movements of the face (1). 

(1) Pratique des Accouchemens, Tom. II, p. 475. 



I8i? COMMON TREATMENT OF SECOND STAGE. 



In the natural progress of the second stage, the 
membranes rupture shortly after the uterine contrac- 
tions assume an expulsiA'C character, and then before 
the child can be expelled, the uterus is gradually pre- 
pared by the tonic contraction to safely revert to its 
vacant state. It is, therefore, with me a fixed rule of 
practice, in all cases ivlthout exception, to rupture the 
membranes, when, the dilatation of the os uteri being 
completed, the pains become expidsive, or even in the ab- 
sence of expidsive pains and with a vieiv to excite them. 
Had this rule been acted upon, in the case cited from 
Madame Lachapelle, there cannot be a doubt, I think, 
that the result would have been different. The mem- 
branes can be easily ruptured in most cases, by pressing 
firmly against them with the extremity of the finger^ 
during a pain, and our aim should be to push the finger 
through them while the pain is at its acme. If the 
simple pressure of the finger is not sufficient, we can 
often succeed by boring with it at the same time. I 
have not found it necessary to notch the fingernail, hke 
a saw, in the manner recommended by Dr. Gooch (an 
accoucheur's nails ought to be always closely pared) ; 
should the finger fail, it would be better to use a probe 
or a writing pen. 

There is yet another reason for the practice here 
recommended, viz., the toughness of the membranes 
may be so great as to seriously retard labor by hinder- 
ing the presenting part from engaging in the pelvis, and 
thus the sufferings of the patient are protracted, and 
the powers of the uterus may be so enfeebled that the 
child wiU not be expelled in good time, after the mem- 
branes give way spontaneously. Dr. Hamilton mentions 



CONDUCT OF IT. 183 



a case (a fortunate one, but conlirniatoiy of the fact just 
stated), where the os uteri was fulty dilated Thursday 
night, but notwithstanding strong and regular pains, the 
membranes were whole on Saturda}^ morning : upon 
rupturing them, a few pains expelled the child. 

Writers, almost unanimously, denounce the practice 
above recommended, and none more strenuously than 
Dr. Francis Ramsbotham. "It is desirable in practice," 
says he, " to preserve the membraneous bag entire as 
long as possible; or, at least, until it has performed the 
whole of the ofHce destined for it by nature; namely, 
the dilatation of the os uteri, the vagina, and somewhat 
of the external parts. When the membranes appear 
externally to the vulva, indeed, we may suppose that 
they have then effected all the good that can be ex- 
pected from them; that thek remaining entire may 
possibly be retarding the labor; and we may in that 
case venture to rupture them, provided the head pre- 
sent. But it is one o^ the first axioms to he learned in 
ohstetric practice^ not officiously or unnecessarily to 
destroy the cyst, so long as any advantage can he gained 
hy its dilating poivers^'^ (1). I agree with Dr. Ram-S- 
botham that the membranes should be preserved, as a 
general rule, until they have performed their office ; but 
do not believe that dilating the vagina, and "somewhat" 
of the vulva, is any part of that office, because," in the 
great majority of cases, they natm-ally give way shortly 
after the os uteri is dilated. I maintain, consecpently, 
that to rupture them when the os uteri is dilated is but 
intelligently to imitate nature, instead of hlindly follow- 

(1) Process of Parturition, new Anner. edition, 1845, p. 92. 



184 COMMON TREATMENT OF SECOND STAGE. 



ing her in all her vagaries. Contrary, therefore, to what 
Dr. llamsbotham has advanced, it is one of the first 
axioms to be learned in obstetric practice, to rupture 
the membranes, whenever their integrity can do no good 
but may do mischief 

Dr. Dewees erred, in my judgment, to the opposite 
extreme, which, though not so pernicious, is not to be 
commended. " Should the pains be efficient," says he, 
" and the os uteri well dilated, or even easilj/ dilatable^ 
and the membranes entire, let them be ruptured by the 
pressure of the finger against them, or by cutting them 
with the nail of the introduced finger " (1). The ex- 
perience and tact of Dr. Dewees may have enabled him 
to pursue this course with safety; but those, less highly 
favored, who may imitate him, will soon have reason to 
repent their rashness. It is not an easy matter to 
know certainly that the os uteri is so dilataUe that it 
will yield readily to the presenting part of the child, 
when this is made to take the place of the membranes; 
and if it do not, the dilatation will be retarded, because 
no part of its body is so well adapted to promote it as 
the soft and pliant membranes. Nay, the process may 
be rendered much more painful as well as protracted, iu 
consequence of the increased resistance of the os uteri, 
provoked by the ruder approaches of the head, should 
this part present. 

In the conduct of the second stage, there is an- 
other matter that deserves to be carefully attended to, 
viz., mfforting the j^e^Hneum from the time it begins 
to he distended until the child is completely exjjelled. 

(1) Midwifery, p. 189. 



CONDUCT OF IT. 185 



The primary object of giving this support is to prevent 
laceration of the perineum, a slight degree of which, it 
has been already stated, unavoidably occurs in nearly 
all first labors ; but the laceration vf ould, doubtless, be 
more considerable in such cases, and of more frequent 
occurrence in all labors, but for the precaution now re- 
commended. To support the perineum, the palm of the 
hand is to be apphed across it, with the index finger 
next the posterior commissure of the vulva, and the 
thumb extended along the outside of one of the labia, — 
forming an arch with the index. The counter pressure, 
made by the hand, should be so regulated as to pro- 
mote, rather than retard, the advance of the child, 
which is accomplished by bearing with most force upon 
the posterior part of the perineum and pressing the 
presenting part toward the symphisis pubis. Pressure, 
exerted in an opposite direction, would act as an im- 
pediment to the emergence of the child, and be much 
more likely to invite, than avert, rupture of the 
perineum. 

In relation to several minor points connected with 
this part of the accoucheur's duty, writers differ consid- 
erably; and it appears to me that Dr, Hamilton at- 
taches more importance to these little matters than they 
deserve. I cannot regard it as of any moment whether 
we apply the naked hand to the perineum, so much in- 
sisted on by Dr, Hamilton, or interpose a folded soft 
napkin. The latter I generally prefer, but if asked my 
reason for it, could, perhaps, assign no other than voila 
ce qui est a nion gri ; and I shall not find fault with 
others, because their taste is different, for de gustihiis 
non disputandiim est. It may be aUowed, however, that 



186 COMMON TREATMENT OF SECOND STAGE. 



in primipariie, where the perineum is long on the stretch, 
and is become sore, dry, and painful, it is commonly 
better to apply the naked hand and make a plentiful 
use of fine hog's lard, which undoubtedly soothes the 
parts and promotes their dilatation. Dr. Hamilton tells 
us that he has used as much as a pound of lard in a 
single case, and with great benefit. 

Again. Whether the patient shall be placed on her 
back or her left side is, I think, a question hardly worth 
disputing about. In France and on the continent gen- 
erally, women are required, by an absolute obstetrical 
decree, to lie on the back, when the time of delivery 
draAvs near, while in England they are as sternly pin- 
ioned on the left side. I commonly prefer the dorsal 
position, simply because I am most accustomed to it ; 
but I never refuse to allow my patient to lie on the left 
side, and I have even had the hardihood to wink at her 
lying on the right side. 

The second stage of labor may be protracted as well 
as the first; and as delay is confessedly most injurious 
here, both to the mother and the child, there can be no 
doubt as to the propriety of expediting it, when this 
can be safely done, or delivering artificially, when the 
natural resources are inadequate, in such time as will be 
most advantageous for all concerned. The most usual 
causes of protraction, in this stage, are, 1, Inefficient 
action of the uterus; and 2, Impotent action of the ute- 
rus. To one or the other of these states of the partu- 
rient organ may be referred every case of labor, retard- 
ed in the second stage, except such as are owing to 
malposition of the fetus, or deformity of the pelvis. 

1. Inefficient action of the uterus. Tliis condition is 



INEFFICIENT ACTION OF THE UTERUS. 187 



indicated by the feeblen&ss or irregularity of the pains, 
and the little or no effect produced by them, in advan- 
cing the child, notwithstanding the absence of any as- 
signable obstacle, — the presentation being favorable, 
and the parts in a healthy state. It may be the con- 
tinuance of a corresponding condition that had existed 
in the first stage, or it may manifest itself in the second, 
although the first may not have been particularly 
protracted. 

In the treatment of this condition, the most signal 
good effects may be often derived from blood letting, 
especially where there is any undue excitement of the 
heart and arteries, as shown by the force and fullness of 
the pulse, by heat of the surface, headache, thhst, etc., 
If the bowels be confined, a large dose of castor oil or 
a stimulating saline enema wiU often succeed in arous- 
ing the uterus to more vigorous action. But the reme- 
dy, which is most usually resorted to for this purpose, is 
the secede cornutum or et^^ot. Administered in the dose 
of ten grains to a scruple of the article finely powdered, 
and repeated once or twice, if need be at intervals of 
tw^enty or thirty minutes, it seldom fails to excite pow^- 
erful uterine contractions, which promptly expel the 
child, if all the requisites for an easy delivery exist, viz., 
if the OS uteri be dilated, the vagina and vulva relaxed 
and moist, the presentation natural or such as to offer 
no great impediment to the birth of the child, that is, 
the vertex, face, or nates; and, lastly, if there be no 
disproportion. 

These requisites for a prompt termination of the^ 
labor are so many conditions which must exist, else it 
will be altogether improper, and may be ruinous to the 



188 COMMON TREATMENT OF SECOND STAGE. 



child or mother, to administer ergot. As there is rea- 
son to believe that this powerful article is daily em- 
ployed without such restraints, and that sad havoc is 
committed by it, the consideration of its modus operan- 
di, with its necessary consequences, may serve to inspire 
us with salutary caution in its use. 

From the exposition that has been made of the 
changes induced in the uterine circulation, by the par- 
turient contractions, it is evident that if these contrac- 
tions were not alternated with intervals of repose, the 
fetus would be inevitably destroyed, in every case of 
parturition, before its expulsion could possibly be ejec- 
ted. Such unrespited contractions of the uterus, as we 
have supposed, are, it is very well known, produced by 
ergot; when it is exhibited and takes effect fully, the 
uterus is urged to one long and unceasing effort until 
its contents are evacuated. A radical change is, there- 
fore, induced in the mode of uterine contraction, which 
is tantamount to wresting the process of parturition 
from the hands of nature. No respite from her suffer- 
ings is allowed the mother, — no breathing time for the 
fetus. What wonder, then, if the former is more ex- 
hausted by the labor, and the latter ushered into the 
world completely asphyxiated, — its countenance savoI- 
len and livid, and its vital organs engorged, or oppress- 
ed with extravasations of blood ! 

This ergotic contraction of the uterus may, more- 
over, produce fatal compression of the child's brain, by 
the too rapid molding of the head to the parturient 
passage, where there is any disproportion, or even unu- 
sual resistance, in the soft parts. Under such circum-f ^ 
stances, nature, if permitted to perform her work, would 



INEFFICIENT ACTION OF THE UTERUS. 189 



proceed cautiously and methodically, — content to obtain 
the desired accommodation, in a gradual manner. 

It is strange that many writers and practitioners 
deny that any such pernicious consequences ever result 
from the administration of ergot. If such a position 
be taken after sufficient opportunities to witness its 
effects, the attempt to convince them of theii error Avere 
hopeless. But, for the benefit of the unprejudiced and 
inexperienced, the following extracts are offered, from 
an interesting paper by Dr. J. B. Beck, entitled "Ob- 
servations on Ergot," published in the Transactions of 
the Medical Society of the State of New York, Vol. V. 

" Dr. Ward, of New Jersey, whose experience with 
this article appears to have been extensive, and who 
speaks of it as a valuable agent in many cases, never- 
theless admits the danger which attends the child from 
its use. ' In aU the cases,' he says, *•' in which I have 
given it, unless the child was expelled very soon after 
the powerful contractions came on, it suffered very much^ 
and would lie for some time without breathing.' Again 
he says, ' From my own observations, with regard to the 
ergot, as well as from other correct sources of informa- 
tion, I am led to conclude that, in most cases, after 
giving it, unless the child is expelled in forty minutes 
after the powerful contractions come on, it will be borne 
dead'(l). 

" The late Dr. Wilham Moore, a veteran practitioner 
of obstetrics in this city, after detaihng some cases, 
gives his opinion of ergot in the following terms: ^It 
appears to be injurious to the child at all times ; for in 

(1) New York Med. and Phys Journal, Vol. IV, p. 212. 



190 COMMON TREATMENT OF SECOND STAGE. 



every case in which I have seen it exhibited, the child 
has been stillborn, and in the greater part of them it 
was not possible to restore it to life' (1). 

"Dr. Ilolcombe, of New Jersey, says, ^more children, 
I am satisfied from what I have seen and heard, have 
already perished by the injudicious use of ergot, during 
the few years which have followed its introduction into 
the practice of this country, than have been sacrificed 
by the unwarrantable use of the crotchet for a century 
past '(2). 

"Dr. Davies, of London, reports ten cases in which 
the ergot was used. In four, the child was stillborn. 
In a fifth, the child was apparently stillborn, but soon 
recovered. In all the stillborn cases, it appears that 
the child was not delivered until upward of an hour had 
elapsed after the administration of the ergot. In the 
first, two hours elapsed; in the second, a little more than 
an hour ; in the third, six hours ; in the fourth a little 
over an hour (3). 

"Mr. T. Chavasse, of Birmingham, states that in 
eighteen cases in which the ergot was used, the children 
were stillborn" (4). 

To these testimonies I shall only add that of John 
Patterson, Esq., of Aberdeen, copied fi'om the Edin- 
burg Medical and Surgical Journal, into Braithwait's 

(1) Compendmm of Midwifery, by Samuel Bard, M. D., p. 
214, fourth ed. 

(2) Philadelphia Journal of the Med. and Phys. Sciences, 
Vol. XI, p. 318. 

(3) New England Journal of Med. & Surg., Vol. XV, p. 18. 

(4) Transactions of the Provin. Med. & Surg. Association, 
Vol. IV. 



INEFFICIENT ACTION OF THE UTERUS. i91 



Retrospect of Practical Medicine and Surgery, No. 1., 
p. 133. liis testimony is adduced, not because it is 
needed to strengthen the evidence ah'eady collected, but 
for a purpose that will presently appear. " In eight 
cases where I used the medicine in half drachm doses," 
says Mr. P., "and closely watched its action, it fully an- 
swered my expectations, by acting strongly in less than 
five minutes after it was administered; and I will 
venture to say that, if properly used, given in pro- 
per doses, and the medicine fresh (which it seldom is), 
it never will disappoint the medical attendant as to its 
stimulating eifects. In every one of these cases there 
was in the symptoms produced a uniformity very sur- 
prising ; all the patients expressed their feehngs in the 
same language, viz., that they never felt themselves in 
a similar state, as their pains were never away. Could 
the action, therefore, of this medicine be in any way 
regulated by the accoucheur, I am satisfied that, to a 
great extent, it would supersede the use of instru- 
ments: but until that can be accomplished, it has that 
gi'eat disadvantage, and will always requke to be given 
with extreme caution. Out of this eight cases in which 
I used the ergot, I lost three children, than which no 
stronger evidence need be adduced of its extreme danger. 
In the works which I have read in reference to this med- 
icine, I have been struck at finding so httle allusion made 
to its bad effects upon the child — very few instances 
being recorded of its fatal effects. In the three cases 
alluded to, I satisfied myself, before its administration, 
that the children were not only alive, but apparently 
strong and healthy ; but so soon as the action of the 
medicine commenced, these impressions gradually be- 



192 COMMON TREATMENT OF SECOND STAGE 



came less sensible to me and the mother. On these three 
occasions I regretted very much that no inspection was 
permitted. In two of them in particular, the conjunc- 
tiva was literally gorged with blood ; and I have little 
or no doiibt that death tvas occasioned hy the uninter- 
rupted pressure of the uterus upon the hrain. In that 
way, and by premature separation of the placenta before 
bu'th, produced by the same action, I doubt very much 
if more deaths are not occasioned than by the use of in- 
struments ; at least my experience leads me to that con- 
clusion." 

Braithwait dissents from the opinion which Mr. 
Patterson advances with respect to the modus operandi 
of ergot on the child, and ascribes its death rather to 
the want of proper oxydation and de carbonization of its 
blood. In a word, his explanation corresponds precisely 
with that which I have given. Now, it is proper that 
I should say explicitly, that I have publicly taught this, 
and with as great emphasis as I could, for the last 
eleven years, viz., since the first session of the Medical 
Institute of this city ( 1837-8 ), as numerous pupils 
might testify, and therefore I did not derive it from 
Braithwait, whose Betrospect, No. 1, was not republish- 
ed in this country until 1844, nor in Great Britain, I 
believe, until 1840. Whether it was received from any 
other writer I will not positively affirm, but my impres- 
sion is that it was not. I do not, however, claim any 
great merit for it: it is, in truth, but a very simple de- 
duction from the physiology of parturition, and the pe- 
culiar action of ergot on the womb. 

But the destructive tendency of ergot, as already 
intimated, is not hniited to the child. When prema- 



INEFFICIENT ACTION OF THE UTERUS. 193 



turely or incautiously administered, it may cause rup- 
ture of the uterus, by goading it to exert a degree of 
force incompatible with its integrity, but yet insufficient 
to overcome the obstacles that may oppose it. Especi- 
ally is this true in cases of disproportion between the 
size of the child and that of the pelvis, and when there 
is unusual resistance of the os uteri and perineum. 

Mr. Patterson, in the article referred to, in Braith- 
wait's Retrospect, states that he has not, in a single in- 
stance, found that injury has been done to the mother, 
"thus giving the ergot in one respect," says he, "a great 
advantage over the forceps," and many writers agree 
with him in this opinion, while none, as it seems to me, 
are sufficiently aware of the danger to be apprehended in 
regard to the mother. 

That rupture of the uterus has been often caused 
by the exhibition of ergot, I cannot doubt, after a care- 
ful examination of cases that have been reported in the 
medical journals. One journal published in this coun- 
try, in a single month ( April, 1841 ), not to refer to 
others, contains two cases, in which fatal rupture of the 
uterus was owing to the use of ergot, though the true 
cause of the accident does not appear to have been sus- 
pected by the reporters. It may be useful to give an 
abstract of these cases, — premising that the title of the 
journal, referred to, as well as the names of the parties 
concerned, are suppressed, lest offense should be given, 
and I be accused of a spirit of ill-natured personal criti- 
cism, which does not at all actuate me. 

The first occurred in the practice of , at the 

time one of the editors of the journal. The patient, 
who had given birth to a dead child two years previ- 
13 



194 COxMMON TREATMENT OF SECOND STAGE. 



ously, was taken in labor about four o'clock, P. M., Fri- 
day, 16th March; seven hours afterward the os uteri 
was well dilated, the head presenting in the first posi- 
tion; the protrusion of the scalp indicated its compres- 
sion on account of the small size of the pelvis, and but 
slow progress was made for the next five hours; the 
head became jammed in the pelvis, and was stationary 
for the next eight hours, when twenty drops of the 
wine of ergot were administered " in the hope that more 
efficient contractions of the uterus might perhaps mold 
the head of the child to the cavity in which it was im- 
pacted : " the ergot having no effect, in an hour and a 
half, an attempt was made to dehver with the forceps, 
which failed on account of the pelvis being so absolutely 
filled up with the head, that " it was not possible to in- 
troduce the smallest- sized catheter into the bladder:" 
the patient was next bled and got a scruple of poiudered 
ergot; this was at four o'clock, and at six, the pains leing 
strong^ forty drops of laudanum were given, shortly af- 
ter which the alternate contractions of the uterus entirely 
ceased, and she was attacked with pain in the epigastric 
region and vomiting ; an attempt to deliver with the for- 
ceps was again made, with no better success than at first, 
when it was determined to deliver by embryotomy, 
which was accomplished with great difficulty, and " lit- 
erally with main force." It is not necessary to pursue 
the subsequent history of the case; suffice it to say that 
the patient died, and a post-mortem examination reveal- 
ed the existence of rupture of the uterus, with extra- 
vasation of blood into the abdominal cavity, and intense 
peritoneal inflammation. 

Now, who can doubt but that goading the uterus 



INEFFICIENT ACTION OF THE UTERUS. 195 



witli ergot, to overcoine the insiirmountalble obstacle, of- 
fered by the contracted peMs, was the cause of its rup- 
ture? Ersrot was altoorether inadraissible under the 
circumstances, nor was the case a proper one for the 
forceps. Had the head been perforated, instead of at- 
tempting to " mold it " by ergot, the woman's life 
might have been saved, and the child would have fared 
none the worse. 

The second case, entitled "Utero-Yaginal Rupture," 

is communicated by . The patient was in labor with 

her third child, and had complained of shght pains during 
the whole of the day before the doctor was called : the 
OS uteri was found to be but partially dilated, although it 
was very easily dilatable; he ruptured the membranes, 
wliich failing to improve the labor, ten grains of ergot 
were given with the effect of increasing the pains, but 
these soon beginning to languish, the dose was repeated, 
shortly after which she had a fevj very severe pains. 
The action of the uterus then gradually declined, and 
the OS uteri became less dilatable, for wliich it was 
judged proper to bleed her, but she did not hear the ah- 
str action of Hood tvell, the loss of eight ounces render- 
ing her pulse "weak and frequent;" four hours after the 
bleeding, the os uteri was more dilated, but the pains 
were still weak and inefficient ; an anodyne was given, 
and she was left for the night ; at nine o'clock next 
morning, it was reported that she had passed a very 
restless nighty and had complained much of pains, but 
few of which the patient thought efficient : on examina- 
tion it was found that the os uteri was fully dilated, the 
breech presenting, and advanced three-fourths of an 
inch to an inch lower than at last examination : inef- 



196 COMMON TREATMENT OF SECOND STAGE. 



fectual attempts were made with the hand to bring 
down the feet, and ergot was again administered, but 
did not produce the least effect. It was now deter- 
mined to dehver with instruments ; the feet were with 
difficulty brought down with the blunt hook; the body 
was soon expelled and the arms brought down, but when 
the head came into the pelvis, the patient was so much 
exhausted, that it was deemed prudent to defer the ex- 
trication until the patient was revived by stimulants; 
the head was then delivered with the crotchet, but 
not >vithout extreme difficulty, and there was not the 
least subsidence of the abdominal tumor until the deh- 
very was nearly completed. It is needless to follow 
the further details of the case: the patient died the 
next day after delivery, and the autopsy disclosed me- 
troperitonitis, effusion into the abdominal cavity, with 
coagula of blood, and transverse rupture of the left 
side of the neck of the womb, extending into the vagina. 
The reporter remarks that it would be interesting 
to determine at what time the laceration happened; but 
as there was "no violent screaming at the time of its 
occurrence, followed by vomiting of dark-colored fluid, 
ghastly countenance, oppressed breathing, fainting, etc.," 
he is at a loss to come to any satisfactory conclusion. 
It does not appear to me that there is the least uncer- 
tainty on this point: the symptoms, enumerated by 
him, do not always follow rupture of the uterus, as his 
own case shows; but the declension of the uterine ac- 
tion, succeeding to the few violent pains produced by 
ergot, and the prostrate condition of the system, evinced 
by the inability to bear the abstraction of even eight 
ounces of blood, indicate with sufficient clearness that 



INEFFICIENT ACTION OF THE UTERUS. 197 



the uterus was ruptured by the "few violent pains;" and 
this indication is confirmed by the total failure of every 
means resorted to, to restore sufficient uterine con- 
traction. 

A Httle reflection, but much more, a little practice, 
will satisfy any one that it is not an easy matter to de- 
cide confidently that all the conditions exist, which will 
justify the exhibition of ergot, and it is, therefore, grat- 
ifying to know that, when there is doubt upon this 
point, we have other resources. The manipulations, 
which I have recommended in the fiirst stage, may also 
be usefully employed in the second, with marked effect. 
The anterior margin of the os uteri, although it be suffi- 
ciently dilated to allow the fetus to pass, may be com- 
monly felt behind the pubes, and the finger is to be in- 
sinuated between it and the presenting part of the 
child, in the absence of pain, and press it upward, per- 
forming, at the same time, semicircular movements, as 
already explained. When a pain comes on, the finger 
is still to retain its place and continue its operations, 
unless the cervix contract with such force as to com- 
pel it to give place, in which case it is to be withdrawn, 
but be reintroduced when the pain subsides, and act as 
before. 

It is, however, sometimes the case that the head is 
so low down in the pelvis, and the os uteri so amply 
dilai % that its margin cannot be felt ; still the m.anip- 
ulation, somewhat varied, is capable of exciting the 
uterus to more vigorous contraction. The vagina and 
rectum receive nerves from the hypogastric plexus, and 
the stimulus of pressure with the finger upon the pos- 
terior wall of the vagina arouses the expulsive contrac- 



198 COMMON TREATMENT OF SECOND STAGE. 



tions of the uterus, diaphragm, and abdominal muscles, 
through the same medium that orificial irritation ope- 
rates. To accomphsh this, the finger is to be carried up 
as high as possible, between the head of the child and 
the posterior wall of the vagina, with its feeling surface 
directed posteriorly, and then slowly withdrawn in a 
zigzag hne, making pretty firm pressure as it moves. 
This may be repeated, at short intervals, until more 
powerful uterine contractions are excited, which I have 
known to occur very promptly, and with the effect of 
speedily terminating hngering labor. There is yet 
another means of exciting more efficient action of the 
uterus, preferred by Madame Lachapelle, which I have 
often practiced with good effect, viz., pressure upon the 
posterior part of the labia pudendi and anterior com- 
missure of the perineum, by two or three fingers intro- 
duced within the vulva. "By pressing thus upon the 
transverse perineal and levator ani muscles," says this 
author, " especially when the head is in the vagina, I 
unequivocally obtain advantageous results: a tenesmus 
is excited, which forces the woman to bear down, at the 
same time that it increases sympathetically the spasm 
of the uterus " (1). 

To guard against the abuse of these manipulations, 
I may say of them, as of those recommended in the 
first stage, that they are not intended to dilate, but to 
excite; — in the language of Madame Lachapelle, "as 
dilatations, thek effect is more hurtful than useful, but 
as excitations, they are capable of rendering the great- 
est services." Notwithstanding this explanation, I do 

(1) Premier Memoire. 



INEFFICIENT ACTION OF THE UTERUS. 199 



not flatter myself that ignoramuses will not abuse this 
valuable resource, or that the ill-natured will cease to 
slander it by sneering at "orificial irritation," and by 
prating about "rubbing down the vagina," "stretcliing 
the vulva," etc. Such we must ever leave to their folly 
and spleen. 



200 COMMON TREATMENT OF SECOND STAGE. 



CHAPTER XII. 
IMPOTENT ACTION OF THE UTEKUS. 

The terms " inefficient " and " impotent " are not 
unfrequently used synonymously ; it is, therefore, ne- 
cessary that I should explain the sense in which I em- 
ploy them. By the former, I mean "inadequately 
exerted/' though the ability to act exists in full vigor ; 
by the latter, " inadequately exerted/' because the abil- 
ity to act more vigorously is destroyed. The former is 
the inertie par iorioeur^ the latter the inertie par epii- 
isement, of Madame LachapeUe. It is only necessary to 
observe further, in the way of explanation, that " impo- 
tent action of the uterus " is equivalent to the " power- 
less," "difficult/' and at least two orders of the "labo- 
rious," labors of systematic writers. The matters 
it includes are, therefore, of great practical interest, 
and challenge" the most careful examination of the 
accoucheur. 

We shall, in the first place, inquire into the actual 
condition of the uterus, when it is brought into this 
impotent state, and the influence of this upon the con- 
tiguous parts and the general system. Its condition 
appears to be analogous to that of the muscles of vol- 
untary motion, when these have been inordinately ex- 
erted, that is, there is swelling and stiffness, soreness to 
the touch, and painfulness upon any further exertion. 



IMPOTENT ACTION OF THE UTERUS. 201 



One who takes a long and fatiguing walk, without being 
accustomed to pedestrian exercise, brings the muscles of 
his legs into this condition; and the accoucheur experi- 
ences it in the muscles of his arm, after every case of 
extraordinarily difficult turning, no matter what may be 
his practice in such performances. 

In reference to the muscles of voluntary motion, it 
is well known that these symptoms are produced by the 
engorgement of their tissue, resulting from the unusual 
or prolonged exercise, and that this engorgement may 
run into inflammation, if exercise be persisted in. In- 
flammation, ending in suppuration, is not unfrequently 
thus produced in the femoral muscles of soldiers, after 
forced marches. The deranged balance of the circula- 
tion is caused by the increased afflux of blood to the 
muscles continuing after they have lost the power of 
vigorous contraction; as the contractile power becomes 
enfeebled, the blood is less and less perfectly expelled 
from them, v^hile in action, until its accumulation 
amounts to engorgement. 

That the muscular fibers of the uterus, when ex- 
hausted by the long continuance or severity of the par- 
turient contractions, are in an analogous condition, may 
be inferred from the similarity of the symptoms, as al- 
ready mentioned. Let us look at these more particu- 
larly. The uterus, as far as it can be examined by the 
finger, has lost its natural properties : the cervix, in- 
stead of being cool, moist, and pliant, feels hot, dry, and 
stiff, — this stiffness differing altogether from the rigid- 
ity which arises from preternatural activity of its fibers, 
already noticed as a cause of protracted first stage. 
The stiffness, of which I am speaking, is connected 



202 COMMON TREATMENT OF SECOND STAGE. 



P 



with tiimidit}^, and gives the impression of the tissue o: 
the part being stuffed, so that its natural pliancy is 
destroyed. Both the neck and body of the organ, as 
felt through the abdominal parietes, are sore to the 
touch, and the parturient contractions are in themselves 
painful ; that is, while they last, the woman complains 
of suffering, diffused over the whole extent of the uter- 
ine globe, which is not much harder than during the 
intervals. 

These contractions have no effect as to the advance- 
ment of labor, — the presenting part of the child re- 
maining stationary, and becoming swelled on account of 
its being begirded by the rigid circle of the os uteri. 

The impotent action, exerted by the uterus in bad 
cases of exhaustion, is often revealed to an experienced 
practitioner, by the altered expression of the pains, and 
the behavior of the woman during their continuance. 
The pains are irregular in their recurrence, last but a 
short time, and are accompanied with httle or no bear- 
ing-down effort ; they inspire the patient with no cour- 
age or hope; hence she endures them impatiently and 
doggedly. 

This morbid state of the parturient function never 
exists, however, without producing more or less local 
and constitutional disorder. The pressure of the pre- 
senting part of the child upon the soft parts lining the 
pelvis and the organs contained within it, disturbs their 
circulation and innervation, and hence they become con- 
gested, and not unfrequently inflamed, — the inflam- 
mation, like that produced by a similar cause in other 
parts, having a marked tendency to ulceration and 
sloughing. Hence, the patient may escape from the 



II 



IMPOTENT ACTION OF THE UTERUS. 203 



danger that threatens her, but have an extensive fistu- 
lous communication between the vagina and rectum or 
bladder. The stomach is disordered, and the patient is 
distressed with nausea and vomiting ; fever is kindled, 
the pulse being permanently accelerated, accompanied 
with thirst, heat of the surface, flushing of the cheeks; 
the nervous system is affected, and the mind begins to 
wander. 

The state of the uterus and maternal system, in im- 
potent labor, is firaught with danger to the child, and if 
the struggle be so protracted as to jeopard the mother, 
its life is commonly forfeited. The observations of Dr. 
CoUins, in the Dublin Lying-in Hospital, led him to the 
conclusion that where the patient has been properly 
treated, from the commencement of her labor, the death 
of the child takes place, in protracted and difficult cases, 
before the symptoms become so alarming as to call for 
delivery on her own account (1). The changes of the 
uterine circulation, described in a former chapter, are 
not, it is probable, so great here as in energetic or er- 
gotic labor (the blood is not so perfectly excluded from 
the uterine tissues during the parturient contractions) ; 
but there is a permanent lesion of the uterine ckcula- 
tion, viz., engorgement, which unfits it for arterializing 
the fetal blood in a healthy manner ; and, besides, al- 
though the muscular contractions be impotent, the tonic 
contraction is in full exercise, and keeps up constant 
pressure on the child's body, which is so much the more 
injurious as the amnion is drained of its waters by 
dribs. 

(1) Practical Treatise on Midwifery, Boston, 1841, p. 17. 



204 COMMON TREATMENT OF SECOND STAGE. 



It is always desirable, and sometimes practically 
useful, to know certainly whether the fetus be alive or 
dead; and we may as well here, as elsewhere, inquire 
whether such knowledge is attainable. Various signs 
of the life or death of the child, during labor, have been 
enumerated by authors, but they are all more or less 
fallacious, with the exception of those furnished by aus- 
cultation. It is true that if the head present, and no 
swelling be formed upon it, notwithstanding the labor 
has been long protracted and has become impotent, 
more especially if, at the same time, its integuments are 
flabby and shppery, and bones loose and disjointed, offer- 
ing their sharp angles or edges, — we may conclude 
certainly, not only that the child is dead, but that it died 
before labor commenced ; for had it been alive, then such 
a cranial swelling would necessarily have been formed, 
by the long continuance and severity of the labor. But 
the existence of this swelling does not prove that the 
child isy but only that it tvas, alive since labor com- 
menced. We are, indeed, told that if the child be alive? 
this swelling is tense and elastic, whereas if the child be 
dead, it is flabby and crepitant, and the bones are loose 
and disjoined; but some time must elapse after the 
death of the child before the sweUing will exhibit these 
altered characters, in such a marked degree as to leave 
no doubt, and it may be that, during this intervening 
time, we are most anxious to solve the question of the 
child's life or death. 

It is not necessary to waste more time in consider- 
ing other signs, either in head or other presentations, 
that have been commonly relied on; suffice it to say, 
they are all deceptions, or only occasionally available. 



I 



IMPOTENT ACTION OF THE UTERUS. 205 



How valuable, then, is the aid which we can derive from 
auscultation, and how important is it that all, who prac- 
tice obstetrics, should seek an experimental knowledge 
of it ! The tree of this knowledge does not, as some 
vainly pretend, grow only in foreign chmes; it does not 
spread its branches only about large hospitals, but its 
fruit may be gathered as well everywhere, — in the 
private mansion, and even in the solitary hut. A little 
patience and perseverance are necessary to train the ear 
so as to detect at first the sounds it is in quest of: but 
these, once discovered, are ever afterward easily recog- 
nizable. 

On applying the ear to the abdomen of a woman 
in advanced pregnancy, if the fetus be alive, the action 
of its heart can be discovered by the sounds emitted 
from it. These sounds, compared by Kergaradec to the 
ticking of a watch, may be recognized as cardiac by 
their resemblance to those of the adult heart, with which 
they cannot be confounded, on account of their much 
greater frequency. The action of the fetal heart is 
much more easily discoverable in the second stage of 
labor, because the liquor amnii being discharged in whole 
or in part, it is brought nearer to the walls of the 
mother's abdomen. The examination being made in the 
interval of the pains, a practiced ear will not unfre- 
quently hear the cardiac sounds, the instant it comes in 
contact with the abdomen. 

If it be discovered that its heart is in action, the 
evidence of the life of the child is, of course, complete. 
But if we fail to make this discovery, it has been ques- 
tioned whether the evidence of its death is quite as 
satisfactory. The proof is, it is true, of a negative char- 



206 COMMON TREATMENT OF SECOND STAGE. 



acter, and it is certainly possible that the child may be 
alive ; and yet, owing to its peculiar situation in the 
uteruSj we may not succeed in detecting the action of 
its heart. I cannot but beheve, however, that if a care- 
ful examination of every region of the abdomen, occu- 
pied by the gravid uterus, discloses no trace of the 
heart's action (supposing, of course, that the examiner 
has the requisite experience and tact), the fetus has lost 
its vitaht}^, or at least the probabihty of this is too 
great to justify us in adopting any method of delivery, 
based on a contrary supposition. The fetus is, there- 
fore, dead to all practical intents and purposes. Under 
certain circumstances, the cessation of the cardiac 
sounds is conclusive proof of the child's death as occular 
examination could afford; I mean v^^here, in the early 
part of the labor, we can distinctly hear these sounds, 
but discover that they grow less and less audible, as 
labor progresses, until they become entirely extinct. My 
own practice is to seek an early opportunity to apply 
my ear to the abdomen, in every case of labor; and then, 
if the labor should be protracted, I have a sure index of 
the child's condition, which should always be taken into 
estimation, when we are deliberating as to what measures 
shall be adopted. 

There is another auscultatory sign of the child's life 
or death, which, though of inferior value to the one just 
considered, is worthy of some attention; — I allude to 
the uterine souffle. While the child continues ahve, the 
general tone of the uterine circulation, on which its wel- 
fare so intimately depends, is maintained ; but when it 
is dead, the motive being lost that had excited it to a 
high rate of vital activity, the uterus falls into a lethar- 



t 



IMPOTENT ACTION OF THE UTERUS. 207 



gic state^ and neither its circulationj innervation, nor 
muscular contraction is performed with as much vigor as 
before. No wonder, then, if the uterine souffle should 
become faint or altogether extinct, after the death of the 
fetus, and this is, as far as my observation goes, gener- 
ally true. 

Dr. Kennedy's more enlai'ged observations are to the 
same effect. In the majority of cases, according to him, 
this sound ceases, and in the instances in which it con- 
tinues, it is impah'ed and differs fi'om the usual sound : 
" It is observed," says he, " to be more abrupt, of shorter 
contmuance, AYanting its protracted terminating whiz, 
and generally confined to a ckcumscribed spot. In 
some cases it is even little more than a pulsation, such 
as is observed on applying the instrument (stethoscope) 
over one of the large arteries (1), 

But although the uterine souffle is annihilated or 
greatly modified by the child's death, we oftener fail to 
detect it than the cardiac sounds, though the child may 
be ahve. We should hardly be warranted, therefore, in 
drawing a positive conclusion from this alone ; but un- 
doubtedly it may serve to corroborate the proof afforded 
by the absence of the cardiac sounds : while, on the 
other hand, should the uterine souffle be discovered, full 
and distinct, we should hesitate to affiirm the child's 
death, even though we fail to hear its heart. 

I cannot dwell longer on the signs of the life or 
death of the child, but must proceed to notice the 
causes of iderine impotency. According to the doctrine, 

(1) Observations on Obstetric Auscultation, New York edition, 
1843, p. 242. 



208 COMMON TREATMENT OF SECOND STAGE. 



which I have endeavored to maintain, whatever is ca- 
pable of seriously protracting the first stage of labor, 
may be reckoned a cause of impotency in the second 
stage. Of the causes that strike at the second stage 
through the first, I have already spoken, and need not 
repeat what has been paid. But I may be allowed, I 
hope without a breach of charity, to say here that, if the 
doctrine referred to be sound, the indirect causes of this 
class are all those expectant practitioners, who consider 
it treason against nature to %tir a finger in contraven- 
tion to any of her vagaries in the first stage. In plain 
terms, it is my decided conviction that mismanagement 
of the first stage is a fruitful source of incompetency in 
the second. 

Dr. Churchill, in his chapter on "Powerless Labor," 
admits our doctrine within a certain range, by no means 
a limited one, where he says, " Women of a iveak con- 
stitidion, especially in their first confinement, not un- 
fi^-equently find the uterine powers fail, after some hours 
of endurance, and that without our being able to re- 
store them. These are the cases, and these only, in 
which there is any thing to fear from a prolonged first 
stage; for the exhaustion produced ly it, and tvhich in 
healthj tvomen is of no consequence, may he the cause 
of inefficient (impotent) action in the second. In wo- 
men of an irritable nervous temperament, there is also 
occasionally a failure of uterine powers in the second 
stage." 

Mismanaged first stage is not, however, the only 
cause of impotent second ; for. 

First. Although there may have been no injurious 
delay in the first stage, the action of the uterus may be 



IMPOTENT ACTION OF THE UTERUS. 209 



simply inefficient in the second; and if this inefficiency is 
allowed to continue, it will more certainly and rapidly 
end in inipotency than in the first stage. Here again, 
with my views of the subject, I am constrained to be- 
lieve that the mischief that results is generally charge- 
able to the inefficiency of the practitioner; for had he 
required the uterus to use its powers to the best effect, 
instead of dallying with them, it might have been pre- 
vented. 

Secondly. The first stage may have been performed 
in good time, and the uterus may act well in the second, 
but, notwithstanding, have its powers exhausted by the 
extraordinary resistance of the perineum and orificium 
vagina, by the malposition of the child, or by its relative 
large size. Malpositions belong to the special phenom- 
ena of the second stage, and will be hereafter considered ; 
but the relative large size of the child, regarded as an 
obstacle to labor, may be considered here. By this 
phrase, I mean too great magnitude of the child, not as 
compared with other children, or with the capacity of 
other pelves, but the pelvis of its mother. The child 
may, in this sense, be large, although it be under the 
ordinary dimensions, or it may be small, although larger 
than common. 

The relative large size of the child is often wrong- 
fully accused of being the cause of delay in the second 
stage. The accusation is easily made, and, no matter 
how false, the touch is readily suborned to prove it. 
The diagnosis of disproportion between the child and 
the pelvis is not so palpable as might be supposed ; for, 
except in extreme cases (where there is actual defor- 
mity), the touch cannot estimate it, so as to enable us 
14 



210 COMMON TREATMENT OF SECOND STAGE. 



to determine whether it is really the cause of difficulty, 
much less to decide that the child cannot be made to 
pass by vigorous contractions of the uterus. The only 
tangible evidence, upon ^Yhich I place the least rehance, 
is the head remaining stationary, notwithstanding the 
pains continue regular and strong, and the gradual ap- 
proximation, and eventually the overlapping, of its bones, 
together with an extraordinary degree of flexion, bring- 
ing the posterior fontanel nearly or quite to the center 
of the pelvis. This is evidence which is only attainable 
in head presentations, and in its absence we must be 
content with probability. All the signs, enumerated by 
authors, are entitled to no more weight, and most of 
them belong to all impotent labors, by whatever causes 
induced. Thus, the pelvis being so filled with the pre- 
senting part as to leave no space for the introduction of 
the finger between them, or for the passage of a cathe- 
ter into the bladder ; retention of urine, acute pain, on 
pressure in any part of the abdomen, hurried pulse, and 
failing strength, while the progress of the head is ar- 
rested, — mentioned by Dr. Collins as signs of dispro- 
portion, — all these are observable in any bad case of 
difficult labor. The progress of the head is stayed by 
the want of sufficiently potent uterine contractions ; 
while the engorgement of the uterus and pelvic viscera, 
together with the sweUing of the child, as effectually 
fills the pelvis as disproportion ever does. There is one 
other sign, given by Dr. Collins, which is, perhaps, en- 
titled to more weight, viz., the continuance of regular 
and strong uterine action for twelve or twenty-four 
hours after the os uteri is dilated, or nearly so, without 



IMPOTENT ACTION OF THE UTERUS. 21 1 



any progress : but here tlie want of progress may be 
owing to other causes, malposition for instance. 

It is not intended to deny the reahty of too great 
relative magnitude of the child as an obstacle to labor, 
which is occasionally met with in practice ; but when 
this occurs, it derives all its importance from its power 
to wear out the energies of the uterus and bring it 
into the impotent state, which so many other causes 
may, and in fact much more frequently do, produce. In 
confirmation of this remark, it may be confidently af- 
firmed that, had the uterus the inexhaustible energy 
wliich some seem to suppose, it would triumph over any 
case of disproportion that could occur, by compressing 
the yielding pai^ts of the fetus and molding them to the 
parturient passage. None can doubt this, who has wit- 
nessed the rapid strides of a vigorously contracting ute- 
rus, in the face of disproportion, malposition, or any 
other obstacle that can be surmounted by force. I con- 
clude, therefore, that it is of much more importance to 
husband the resources of the uterus, and bring them into 
requisition at the proper time, than to busy ourselves in 
trying to measure the child and pelvis. 

In the treatment of uterine impotency, but little le- 
liance is to be placed in the remedial measures which are 
appropriate to inefficient action of the uterus. Blood 
letting is seldom indicated, and if used largely with a 
view to make a decided impression on the system, is not 
free from danger, on account of the general exhaustion 
of the vital powers. Nor is any effect, either salutary 
or otherwise, to be expected, as a general rule, from the 
administration of ergot. The reason is obvious ; ergot 
is an excitant of the uterus, but it cannot restore the 



212 COMMON TREATMENT OF SECOND STAGE. 



lost excitability of the organ, much less can it restore 
its tissues to their healthy condition ; and until this is 
done it is not possible for the uterus to be aroused to its 
wonted energy of contraction. In the incipient stage of 
the affection, the remedy may succeed; but when it is 
confirmed, it were a waste of time to expect any benefit 
fi'om this quarter. If those who are in the habit of pre- 
scribing ergot were always careful to distinguish between 
cases of mere inefficiency and decided impotence, they 
would be less frequently disappointed in their expecta- 
tions fi-om the article, and we should hear less of the un- 
certainty of its operation. This medicine will, I am 
persuaded, seldom fail to excite the uterus in a decided 
manner, in any case proper for its use, viz., where, the 
conditions already specified existing, the uterus is in a 
state of torpid inertia ; but it cannot reach inertia fi:om 
exhaustion. 

Not much more promising are the fingers, employed 
in the various ways already described, for the purpose 
of stimulating the uterus. They, like the ergot, may 
succeed in the commencement, but not in the confirmed 
stage, of impotent labor. What, then, is to be done ? 
Shall the case be allowed to take its course, or shall we 
interpose, and at what time, and under what circum- 
stances, will artificial delivery be justifiable ? These are 
important questions ; much of the future comfort of the 
patient, nay, her life itself and that of her offspring, 
will depend upon the manner in which they are answer- 
ed in each particular case ; and yet, in a discussion like 
this, it is impossible to answer them otherwise than in a 
very general manner : for, from the nature of the sub- 
ject, much must be left to the sober judgment and ex- 



IMPOTENT ACTION OF THE UTERUS. 213 



perience of the practitioner. If, on the one hand, nature 
be trusted to, she msLj, after a painful and protracted 
struggle, prove victorious, or ( for she abhors the en- 
tombment of the child in its mother's womb ) a dead 
child may be ushered into the world as a prelude to the 
mother's departure from it. If, on the other hand, we 
have recourse to dehvery, harm may result from its be- 
ing too long deferred; or, if we resort to it early, and 
any accident happen, we may be reproached for our 
precipitancy. 

Looking at the subject in a general light, I would 
say that tune is no criterion to govern us. The march 
of time is not uniform in its effects on labor, any more 
than it is on the persons of the sex; — in the lapse of 
a given number of hours, some women will be brought 
into a perilous condition, while others, under similar cu'- 
cumstances, as far as we can judge, will be in no man- 
ner of danger. In forming our opinion as to the neces- 
sity of artificial delivery, our attention should be directed 
to the evidences of uterine impotency ; in proportion as 
these thicken, the necessity of delivery becomes more 
and more urgent. It is not wise to wait until the ur- 
gency is extreme; and in general, the earlier the woman 
is relieved by dehvery, the better, provided this can be 
done with facility and safety. Suppose, for example, 
the head of the child is presenting and has ceased to 
advance, while the uterus has evidently become impo- 
tent : suppose, moreover, this head is within easy reach 
of the forceps, and can be dehvered without risk or 
additional pain to the mother, — what would be the use 
of waiting until we are driven to the operation? But if 
delivery be not so easily and safely practicable, pru- 



214 COMMON TREATMENT OF SECOND STAGE. 



dence requires that it should be deferred until the ne- 
cessity of it i$ more pressing, — so pressing that, in our 
judgment, it is better to incur whatever risk the opera- 
tion may involve, than wait longer. 

The mode of delivery, instrumental or manual, de- 
pends upon the presentation of the child, and will be 
considered as a part of the special treatment of the se- 
cond stage, upon which we are shortly to enter. 



PRESENTATIONS AND POSITIONS. 215 



CHAPTEE XIII. 
PRESENTATIONS AND POSITIONS OF THE FETUS. 

The special phenomena of the second stage of labor, 
being, as I have said, such as belong to the different 
presentations and positions of the fetus, must, of course, 
be studied in connection with them. A general view of 
this branch of our subject will be attempted in the pre- 
sent chapter. 

We have seen that in the most usual situation of the 
fetus, especially during the last months of pregnancy, 
and consequently when labor sets in, the head is its de- 
pendent part. The head is, therefore, most frequently 
found presenting at the superior strait. But other parts 
may, from various causes, usurp the place of the head ; 
and, as the process of expulsion is materially affected 
by these differences of presentation, their careful study 
is essential to any correct knowledge of the mechanism 
of labor. 

Most recent writers on obstetrics employ the terms, 
presentation and position^ in reference to the situation 
of the fetus at the time of labor; — meaning, by the 
former, the part which offers at the superior strait, — by 
the latter, the relation of this part to different points of 
the strait. I shall use these terms in accordance with 
this definition ; but shall, also, take the liberty to con- 



2ie SPECIAL PHENOMENA OF SECOND STAGE. 



sider presentations as genera, and positions as species, 
in any systematic classification of them. 

The celebrated Baudelocque is, perhaps, to be regar- 
ded as the first obstetrical writer, who attempted to col- 
lect and classify every kind and species of presentation, 
which either his own experience or a perusal of the cases 
of his predecessors furnished him. His elaborate re- 
searches resulted in the establishment of such a multi- 
tude of presentations and positions as is truly appalling, 
and calculated to perplex, if not to disgust, the most 
zealous pupil in this branch of his studies. Not that M. 
Baudelocque did not arrange the mass of materials, 
which his industry collected, as judiciously as was, per- 
haps, possible, allowing that they were all equally essen- 
tial to the edifice he was laboring to construct ; but if 
such be really the complexity existing in nature, the 
student might well despair of mastering it, and the 
practitioner tremble at the idea of encountering it. 

M. Baudelocque 's classification embraced twenty- 
three genera of presentations, consisting of as many dis- 
tinct regions of the fetal body, which he supposed might 
offer at the superior strait. Four of these genera he 
found at the cephalic and pelvic extremities of the fetus, 
viz., presentations of the vertex^ of the feet^ hiees, and 
nates, — while the four planes of the body, between these 
extremities, furnished him, — the anterior, with ih.Q face, 
the forepart of the neck, the hreast, abdomen, and thighs 
(five genera) ; the posterior, with the occiput, nape of 
the neclc, the hack, and loins (four genera) ; and each of 
the two lateral, with the side of the head, side of neck, 
the shoulder, side of thorax, and the hip (ten genera). 
These genera include ninety four species, which it would 



PRESENTATIONS AND POSITIONS. 217 



be as useless as tedious to enumerate. Many of these 
presentations he does not pretend to have met with in 
practice, but admits, on the authorit}'^ of a single ob- 
server, whose accuracy may be questioned, and whose 
love of the marvelous may have misled him. To these 
apochryphal presentations he assigned such positions as 
they might possibly allow. 

It is, however, due to the memory of the illustrious 
Baudelocque, to whom we owe so much, to state that he 
lived to perceive the inconvenience of his elaborate and 
highly artificial classification, as we learn from Madame 
Lachapelle, who doubts not that he would, had his life 
been longer spared, have reduced and simplified it. 
This necessary reform was undertaken by his successors, 
MM. Gardien, Capuron, Maygrier, Duges, Madame La- 
chapelle, etc. It would be tedious to trace its progress? 
and I shall, therefore, content myself with a survey of 
its completion, under the auspices of Madame Lacha- 
pelle, and her nephew, M. Duges, In saying that 
Madame Lachapelle and Duges have completed this 
deskable reformation, I must be understood to express 
only my own opinion; I am not unaware that still 
greater simplification has been attempted by others, 
chiefly by Professor Nsegele in Germany, seconded by Dr. 
Rigby in England, and Professor Dubois in France. Of 
their attempt I shall presently express my judgment. 

The ample experience of Madame Lachapelle, acquired 
in the Paris Maternity, where she officiated or directed 
in as many as forty thousand cases of labor, not having 
offered a single instance of presentation of the trunk, 
she denied altogether the possibility of any such occur- 
rence, where the fetus is fully developed. By a critical 



218 SPECIAL PHENOMENA OF SECOND STAGE. 



examination of the few cases of this kind, recorded 
by her predecessors, principally by Delamotte, Portal, 
Smellie, and Burton, she shows conclusively that they 
were really nothing more than perversions of such pre- 
sentations as she admits. Her own experience author- 
ized her to retain only the seven following genera, viz., 
presentations, 1. Of the vertex ; 2. The breech ; 3. The 
feet ; 4. The knees ; 5. The face ; 6. The right shoulder; 
7. The left shoulder. Under these genera are included 
twenty-four species, viz., six belonging to the vertex ; 
four to the breech, four to the feet, four to the knees, 
two to the face, tivo to the right, and two to the left, 
shoulder. To each of these species belong several va- 
rieties, which are merely intermediate or incomplete 
positions, as, for example, when the posterior fontanel, 
in vertex presentation, looks toward any other than 
what are called cardinal points of the superior strait ; or 
when the head is inchned so as to offer the occiput or 
forehead, or one of its sides, instead of the vertex, to the 
superior aperture of the pelvis. Similar deviations from 
the normal positions of the face and breech may exist as 
varieties, and these mere varieties have given rise to the 
pretended positions of the back, forehead, and side of the 
head, the back and fore part of the neck, the hips, loins, 
abdomen, etc. 

It does not, however, require much observation of 
nature, or any great profundity of reflection, to satisfy 
any one, whose judgment is not biased by preposses- 
sions, that three of the genera of Madame Lachapelle, 
viz., the breech, feet, and knees, may be properly united 
under one, because there is no essential difference be- 
tween them, either in relation to their mechanism, or the 



PRESENTATIONS AND POSITIONS. 



219 



treatment they require. They cannotj therefore, be 
considered separately without tiresome and unprofitable 
repetition. Accordingly, M. Duges has united them 
under the common denomination of presentations of the 
pelvic extremity of the fetus. It is but justice to Ma- 
dame Lachapelle to state, that she had a clear perception 
of the utihty that might result fi:om such a union, and 
was restrained fi'om proposing it, only by the apprehen- 
sion that she might be accused of pushing her reform 
too far (1). The classification of M. Duges, which I 
adopt, admits but five genera and fourteen species of 
presentations, and is advantageously exhibited in the 
following synopsis, extracted from his work (2), in 
which is, also, shown the comparative frequency of the 
difierent presentations and positions in a total of thirty- 
seven thousand one hundred and twenty-six cases of 
labor, occurring in the Paris Maternity in the course of 
eighteen years. 



Genera. 



I. Vertex; 35,375. 



11. Pelvis; 1,390. 



in. Face; 



175. 



Species. Frequency. 

1st. Back anterior and left ; 27,443 

2d. " anterior and right ; 7,512 

3d. " posterior and riglit ; 276 

4th. " posterior and left ; 144 

1st. " left; - - - - -854 

. 2d. - right; - - - 494 

^ 3d. '• anterior; - - - 14 

4th. " posterior; - - 26 

1st. " left; - - - - 99 

2d. " riffht; - - - 76 



(1) Pratique des iiccouchemens, Quatrieme 3Ieraoire. 

(2) Manuel d' Obstetrique. 



220 SPECIAL PHENOMENA OF SECOND STAGE. 

Genera. 
IV. Ri^ht 



Species. 
slioulder; 103. ^^^• 

boulder; 83. | J^*' 


Back anterior; - 

" posterior; 
" ante^-ior; - 
" posterior; 


Frequenx^y. 

- - 57 

- - 46 

- - 52 

- - 31 


14 


87,126 



In this classification, it will be perceived, the genera 
and species are arranged according to their frequency^ 
respectively, with the exception only of the fourth posi- 
tion of the pelvis. The regularity of its principle of 
division, as its author justly remarks, gTeatly facilitates 
the recollection of it : the laclt of the fetus serves as the 
point of comparison, and is placed anteriorly or to the 
left, in the first species, of each genus — posteriorly or 
to the right, in the last. 

It has been already intimated that MM. Nagele and 
Dubois, with a praiseworthy ambition to divest this 
part of obstetrical science of its complexity, have car- 
ried their reform farther than M. Duges, and aimed to 
establish a degree of simplicity, which ought to be wel- 
comed, if it be found to be true to nature. In ex- 
hibiting their views, I shall avail myself of the work • 
of M. Cazeaux, heretofore quoted, as the only channel 
through which I have access to them; for, in the only 
work of Professor Nsegele which I have consulted, viz., 
his "Mechanism of Parturition," translated by Dr. 
Rigby, I do not find all the information needed. 

MM. Nsegele and Dubois agree with M. Duges in 
admitting only five presentations, viz., vertex, face, pel- 
vis, right and left shoulder; but Dubois prefers to de- 
nominate the latter two, presentations of the right and 
left lateral planes of the trunk — acknowledging, how- 
ever, with ^ladame Lachapelle,that it is almost always the 



PRESENTATIONS AND POSITIONS. 221 



shoulder wMcli, as the most prominent part, is found 
presenting at the superior strait. As to the loresenia- 
tions of the fetus, there is, then, no difference between 
these authors. But, says M. Cazeaux, Baudelocque and 
his successors admitted a great number of positions, in 
each of which the mechanism of labor is different ; and 
M. Nsegele has, after a more careful study of them, pro- 
posed a reform relative to positions, not less important 
than that which he has brought about in regard to pre- 
sentations. To indicate the different positions, Baude- 
locque estabhshed certain points of the superior strait, 
viz., the acetabula, the sacro-iliac, and pubic symphyses, 
and the promontory of the sacrum, to which certain points 
of the fetus correspond. But M. Nsegele simply di- 
vides the pehds into two lateral halves, left and right, 
and these are his only points of correspondence as to 
the mother, while, as to the fetus, Baudelocque's points 
are retained. The vertex, for example, being the pre- 
senting part, the occiput may be turned toward any 
part of the left lateral half of the superior strait : — this 
constitutes the first position of the vertex, denominated 
left occipito-iliac] — or the occiput may be du-ected to- 
ward any part of the right lateral half of the strait, 
constituting the second, or right occiioito-iliac^ position 
of the vertex. The occiput may, it is true, look for- 
ward, transversely, or posteriorly, still it is placed more 
or less laterally; and these are to be regarded as mere 
varieties of two fundamental positions, because they do 
not affect the mechanism. Three varieties are admitted 
for each position, viz., an anterior ^ in which the occiput 
looks toward the acetabulum; a transverse, in which it 



"22-2 SPECIAL PHENOMENA OF SECOND STAGE. 



looks directly toward the side, and a posterior, in which 
it looks toward the sacro-iliac symphyses. 

The same remarks are equally applicable to the po- 
sitions of the nates and face. Thus, in the first of these 
presentations, the sacrum of the child may be directed 
toward the left lateral half of the superior strait (the 
first or left sacro-iliac position of the nates), or it may be 
directed toward the right half of the strait (the second 
or ri(/ht sacro-iliac position of the nates). In face [pre- 
sentations, the chin may be directed to^vard the right 
half of the superior strait, — first or right mento4liac po- 
sition, — or toward the left half, — second or left mento- 
iliac position. Finally: The two trunk presentations 
have each two positions: thus, the right lateral plane 
being the presenting part, the head of the fetus may be 
over the left half of the pelvis, constituting its first or 
left cephalo-iliac position; or over the right half, its 
second or right cephalo-iliac position. The left lateral 
plane may, in hke manner, be so placed that the head 
is to the left (its first or left cephalo-iliac position), or 
to the right (second or right cephalo-iliac position). 
The two fundamental positions of presentations of the 
nates, face, and right and left lateral planes of the 
trunk, admit anterior, transverse, and posterior varia- 
ties in the same manner as those of the vertex. 

From the foregoing summary of their scheme, it must 
be manifest to the reader that MM. Nsegele and Dubois 
have reduced the number of presentations and positions 
to thek ultimatum. It is not possible to conceive how 
any farther purgation could be practiced without a total 
destruction of the species at least. The apparent sim- 
plicity they have attained, commends their classification 



PRESENTATIONS AND POSITIONS. 223 



to our approval ; but before adopting it, we should in- 
quire whether it embraces everything, and accords with 
the principle which ought, undoubtedly, to govern it. 
The principle is this: Whenever the ]Jresence of any part 
of the fetus at the superior strait of the pelvis requires 
a mechanism of its oivn, it is entitled to rank as a pre- 
sentation; and if different relations of this part to the 
superior strait do, or even man, affect its mechanism, 
these differences ought to constitute so many distinct po- 
sitions 0^ tlie presenting part. M. Naegele admits the 
validity of this principle, when he asserts, as a reason 
for uniting into one position the several varieties which 
he allows to each, that the mechanism of labor is not 
affected by these varieties. But this assertion is at va- 
riance with the experience of all his predecessors, and 
is not admitted to be correct by most of his cotempo- 
raries, as will be shown when the mechanism of labor is 
under discussion. 

Again. This classification allows no place for those 
positions of the nates in which the back of the fetus 
looks directly forward or backward (third and fourth of 
of Duges), which ought not to be excluded, because they 
are undoubtedly of sufficiently frequent occurrence to 
be entitled to a place, and their mechanism is not always 
the same as that of lateral positions. 

AUusion has been made to the apparent simphcity 
of the classification we are considering ; it is but justice 
to say that this feature of it is entu^ely deceptions, and 
that in reality it is as multiplex as though six positions 
had been assigned to each presentation instead of two. 
Admitting that shades of difference only exist among 
its varieties, in regard to their mechanism, still we are 



224 SPECIAL PHENOMENA OF SECOND STAGE. 



compelled, for precision's sake, -to refer to them, and this 
makes the nomenclature of position cumbersome. Sup- 
pose, for example, it be deshable to note the pecuharity 
of vertex presentation in any case, it will not be exact 
to say simply left or right occipito-iliac, but anterior, 
transverse, or posterior must be prefixed or suffixed 
thus, left anterior occipito4liac or left occipito-iliac an- 
terior, etc. 

It appears to me that M. Duges has attained as 
great simplicity as the subject of fetal presentation is 
susceptible of, without a sacrifice of perspicuity, and, 
what is of more importance, of conformity to nature. 
Having already adopted his classification, I shall devote 
the remainder of this chapter to some further remarks 
upon it, intended to develop its merits by comparing it 
with others. In doing this it will be necessary to bring 
under review its several presentations, in the order in 
which they stand as already exhibited. 

First; Of presentations of the vertex. 

M. Baudelocque, it is well known, admitted six po- 
sitions of the vertex; in the first, the occiput is turned 
toward the left acetabulum ; in the second, toward the 
right acetabulum ; in the third, toward the symphysis pu- 
bis; inthe fourth, toward the right sacro-iliac symphysis ; 
in the fifth, toward the left sacro-iliac symphysis ; and in 
the sixth, toward the promontory of the sacrum. Four 
of these positions, it will be perceived, are ohlique, and 
two are direct; that is, in four, the occipito-frontal dimen- 
sion of the fetal head corresponds to the oblique diame- 
ters of the superior strait; and in two, to the antero-pos- 
terior diameter, which crosses the strait directly, instead 



PRESENTATIONS AND POSITIONS. 225 



of obliquely. Of the two direct positions, his third and 
sixth, Baudelocque himself declares that they are on ne 
pent 2)lus rares, the third occurring but twice, and the 
sixth once, in ten thousand three hundred and twenty- 
two labors which he had observed (1); while Madame La- 
ehapelle never met with a single instance of either 
of these positions, and declares her opinion that they 
are purely imaginary (2). M. Capuron rejects these 
positions altogether ; 1, because they are exceedingly 
rare ; 2, because in the course of labor, the round sur- 
face of the sacro-vertebral angle will not permit either 
the forehead or occiput, which are also round, to rest 
long upon it, but will force them to glance to the right 
or left and produce one of the positions, which he ad- 
mits (the same as M. Duges) ; 3, because in these po- 
sitions, the head cannot engage in the pelvis, unless it 
be very small or the pelvis very capacious; 4, because 
where difficulty is offered by them, they must be changed 
to a more favorable position (3). Dr. Dewees met with 
only a few cases of these positions, and these occurred 
under the favoring circumstances mentioned by Capuron, 
while my own experience has not furnished me with a 
sohtary instance of them. 

Habit exerts a control which it is difficult for the 
most vigorous and best disciplined mind to resist, and it 
was, I suppose, under its influence that Madame Lacha- 
pelle brought in two new positions to occupy the place 
of the third and sixth of Baudelocque, which she had 

(1) L'Art des Accouchemens, Tom, 1, p. 305. 

(2) Pratique des Accouchemens, Deuxieme Memoire. 

(3) Cours Theorique et Pratique d'Accouchemens, p. 199. 

15 



226 SPECIAL PHENOMENA OF SECOND STAGE. 



expunged. She had, it would seem, become so accus- 
tomed to the number six that she could not dispense 
with it. The two new positions introduced by her, are 
also of the direct kind, the occipito-frontal diameter of 
the head corresponding to the transverse diameter of 
the superior strait — occiput left or right. Although it 
may not be denied that she met with such positions, it 
must be allowed that they are rare, not being men- 
tioned by many authors, and my own experience having 
failed to supply an instance of them. We may well be 
astonished, therefore, that two of the latest writers on 
obstetrics in France and England, M. Moreau and Dr. 
F. Ramsbotham, retain all of Baudelocque's vertex po- 
sitions, and adopt Madame Lachapelle's two new ones, 
making eight in all. M. Moreau divides his eight posi- 
tions into four direct or fundamental, and four indirect or 
oblique, considering the latter as only varieties of the 
former. His four direct positions are, left ocdpito-iliac, 
right occipito-iliac, occipito-puhic, and occipito-sacral, so 
denominated because, in the first two, the occiput cor- 
responds to the extremities of the bis-iliac diameter, 
and, in the last two, to those of the sacro-pubic diame- 
ter. His four indirect or oblique positions are, left ocd- 
pito-cotyloid, right occipito-cotyloid, left occipito-iliac 
posterior or right fronto-cotyloid, and right ocdpito-iliac 
posterior or left fronto-cotyloid (1). 

The oblique positions M. Moreau considers as vari- 
eties of the direct, which he admits to be of rare occur- 
rence. But if the direct positions are rare, it may be 
inquired, with what propriety can they be considered as 

(1) Traits Pratique des Accouchemens, Tom. H., p. 69. 



PRESENTATIONS AND POSITIONS. 227 



fundamental, — as the species, — while the oblique, 
which are constantly occurring, are regarded as varie- 
ties only ? The truth is that the four obhque are the 
usual and natural positions of the vertex; all others are 
but extraordinary deviations from them, and are not 
entitled to rank as positions in a well-ordered classifi- 
cation. 

M. Duges adopts Capuron's nomenclature of vertex 
positions, designating them as follows, viz., 1, left occi- 
pito-anterior ; 2, right occipito-anterior ; 3, right oca- 
pito-posterior ; 4, left occipito-posterior ; it being un- 
derstood that in the first, the occiput is turned toward 
the left acetabulum ; in the second, toward the right 
acetabulum; in the third, toward the right sacro-iliac 
symphysis ; and in the fourth, toward the left sacro-iliac 
symphysis. But, in my opinion, names should be pre- 
ferred which define the positions more precisely: I shall, 
therefore, distinguish them as the left occipito-acetabu- 
lar, right occipito- acetabular^ right occipitosacro-iliac^ 
and left occipito-mcro-iliac^ positions of the vertex. It 
is convenient to have, also, shorter names for them, and 
none are better than the ordinal numbers, first, second, 
third, and fourth, commencing with the left occipito- 
acetabular ( the first in all systems ), and ending with 
the left occipito-sacro-iliac. Again ; it is convenient 
for many purposes to have an appellative for the first 
and second, or left and right occipito-acetabular posi- 
tions, to distinguish them from the third and fourth, or 
right and left occipito-sacro-ihac, positions, for it is some- 
times necessary to refer to them as thus classified. In 
this respect, the appellations of Dugas will be preserved ; 
the first and second being denominated occipito-anterior 



228 SPECIAL PHENOMENA OF SECOND STAGE. 



positions, the third and fourth-, occipito-'posterior posi- 
tions of the vertex. 

The frequency of vertex presentations, compared 
with others, deserves the attention of the obstetrical 
student. By reference to the synopsis of Duges's clas- 
sification, it will be seen that thirty-five thousand three 
hundred and seventy-five vertex presentations occurred 
in a total of thirty-seven thousand one hundred and 
twenty-six deliveries in the Paris Maternity, showing 
the great preponderance of the vertex over all the other 
presentations together. It will be observed, moreover, 
that of these vertex cases twenty-seven thousand four 
hundred and forty-three were first or left occipito-aceta- 
bular positions, seven thousand five hundred and twelve 
were second or right occipito-acetabular, two hundred 
and seventy-six were third or right occipito-sacro-iliac, 
and one hundred and forty-four fourth or left occipito- 
sacro-iliac. These results, as to the relative frequency 
of the several positions, agree substantially with those 
of most authors; but their accuracy has been questioned 
by Professors Nsegele and Dubois, whose contradictory 
observations are entitled to our candid consideration. 
Professor Nsegele avers that in one hundred cases of 
vertex presentation we may generally reckon on seventy 
in the first position, and thirty in the thkd; and that 
the other positions are so exceedingly rare in their occur- 
rence, that they may be regarded as exceptions to the 
general rule. M. Dubois affirms that he has carefully 
noted nineteen hundred and thirteen cases of vertex 
presentation, of which thirteen hundred and fifty-five 
were first positions, fifty-five only were second, four hun- 
dred and ninety-one were third, and twelve were fourth. 



PRESENTATIONS AND POSITIONS. 229 



M. Cazeaux, to whom we are indebted for this informa- 
tion, declares that these results accord with his own 
observations, and those of Professor Stolz, of Strasbourg. 
It is obvious that, between these imposing authori- 
ties on the one hand, and Duges, seconded bj Baude- 
locque, Gardien, Capuron, Boivin, Lachapelle, etc., on the 
other, there is irreconcilable variance. Future experi- 
ence must settle the question of accuracy, I say not of 
veracity, between them, for neither can be supposed 
intentionally to misrepresent. The sense of touch is 
confessedly fallacious, but I should have no confidence 
in it whatever, could I suppose that MM. Naegele, Du- 
bois, etc., are right in this matter, for my touch con- 
tinues, to this day, to make contradictory revelations to 
me : nay, I find, by reference to my note book, that the 
fourth position has occurred in my practice oftener than 
the third, but both together less frequently than the 
second. 

Secondhj; Of presentations of the pelvic extremitif 
of the fetus. 

To this genus of his classification Duges allows the 
four positions assigned by Baudelocque to presentations 
of the breech, feet, and knees, and arranges them in the 
same order. He alters slightly, how^ever, the colloca- 
tion of the fetus in the first and second positions, in 
which he makes the back of the fetus look directly left 
and right, instead of incKning farward at the same time, 
as Baudelocque has it. But Madame Lachapelle ob- 
serves that Baudelocque did not suflftciently consider 
that this forward direction is most frequently imparted 
by the mechanism of labor or the hands of the accouch- 



230 SPECIAL PHENOMENA OF SECOND STAGE, 



eur, and she positively affirms that the direct positions 
are at least as common as the oblique. On this account 
she thinks that the direct positions ought to be consid- 
ered as the cardinal ones, more especially as the division 
of pelvic presentations is thereby rendered more regu- 
lar. In this she is sustained by M. Moreau, who asserts 
that, in most cases, the hips enter the pelvic excavation 
parallel with the sacro-pubic diameter of the superior 
strait, and that it is only when the fetus is very large 
that they engage in the obHque diameters. The four 
positions of the pelvic presentation, then, are all direct^ 
instead of oblique^ as are the vertex positions, or if there 
be a slight deviation from the directness of the first and 
second, this is of no importance, because the mechanism 
is not affected by it. It is not an easy task to pre- 
scribe a suitable nomenclature for presentations of the 
pelvic extremity, either as to the genus or its species. 
The difficulty arises from its complex character, embra- 
cing, as it does, according to our views, presentations of 
the breech, feet, and knees. We cannot, perhaps, do 
better for the genus than to adopt Dr. Rigby's proposal 
to apply the latin word, " nates," to it, which, although 
synonymous with the EngUsh term, "breech," may 
have its signification enlarged so as to include also the 
feet and knees. Accordingly, whenever the phrase, 
" nates presentation," occurs in this work, it is to be 
understood as equivalent to presentation of the pelvic 
extremity of the fetus. 

The same dilficulty exists as to the different posi- 
tions of nates presentation. Had we only to invent a 
name for the relative points of the several varieties it 
includes, viz., breech, feet, and knees, we could be at 



PRESENTATIOxVS AND POSITIONS. 231 



no great loss. We might, for example, use the Latin 
words for these fetal points, and by prefixing them to 
the names of the maternal points, that is, the parts of 
the pelvis of the mother to which they correspond, con- 
struct phrases to define the exact position of the fetus. 
This is, in fact, what has been done. Thus, M. Moreau, 
who adheres to the breech, feet, and knees, as distinct 
presentations, and whose positions correspond to ours, 
denominates the first position of the breech left sacro- 
iliacj the second riglit sacro - iliac, the third sacro- 
piihic, and the fourth sacro-sacral, because the sacrum 
of the fetus ( its relative point ) looks toward the left 
and right ilium, the pubes and sacrum of the maternal 
pelvis, which are its relative points. And in relation 
to the several positions of the feet and knees, the fetal 
portion of their compound names is derived from the 
heels (calcaneum, Latin), and tibiae, because these are 
their relative points; consequently, left calcamo-iliac, 
riglit calcaneo-iliaCj calcaneo-puhic, and calcaneo-sacral, 
express the first, second, third, and fourth positions of 
the feet ; and left tihio-iliac, right tihio-iliac, tihio-piihic, 
and tihio-sacral, indicate the several positions of the 
knees. But as our classification includes all these vari- 
eties under one presentation, our nomenclature must 
be equally comprehensive, and I propose, therefore, to 
make the back ( dorsum., Latin ) the fetal constituent 
of the names of the different positions of the nates ; 
thus, left dor so-iliac, right dor so-iliac, dorso-piibic, dor so- 
sacral, clearly define the relations of the fetus to the 
maternal pelvis, and if the back be not literally in ap- 
position with the different points of the pelvis, in the 
commencement of labor, it must necessarily become so 



232 SPECIAL PHENOMENA OF SECOND STAGE. 



during its progress. Meanwhire, the sacrum, heels, and 
tibiae of the fetus, according to the variety of nates pre- 
sentation that may exist, are the tangible representa- 
tions of the back. 

The frequency of nates, compared with other pre- 
sentations, is shown in the synopsis, from which it will 
be seen that in about one twenty-seventh of all the 
labors in the Maternity, when its statistics were compiled 
by Duges, the nates presented ; and this agrees pretty 
nearly with the calculations of other European obstetric 
institutions. But this proportion is much greater than 
I have observed in my own practice. Not having kept a 
record of all the cases that have fallen under my obser- 
vation, I cannot undertake to state the proportion accu- 
rately, but I am persuaded that it is not greater than 
one fiftieth. By referring to the relative frequency of 
the several positions of the nates, it will be seen 
that the first or left dorso-iliac position is, by far, the 
most common, and that the third or dorso-pubic position 
is the least frequent of all, having been observed only 
fourteen times in one thousand three hundred and ninety 
cases of nates presentation. Allusion is made to this 
point for the purpose of drawing the attention of the 
profession to the discrepant statement of the younger 
Bamsbotham, who says (1), that under breech presenta- 
tion the most usual situation of the child is, with the 
back toward the abdominal muscles of the mother, and 
the face toward the spine. This statement, I suppose, 
can only be explained by Dr. Ramsbotham having 
taken cases of first and second position, with forward 

(1) Process of Parturition, second Amer. edition, p. 238. 



PRESENTATIONS AND POSITIONS. 233 



inclination of the back, for directly anterior positions of 
the back. 

As to the relative frequency of the several varieties 
of nates presentation, it need only be observed that 
breech cases are more common than feet (I will not 
deface my page with " footling "), and that the knees 
are seldom met with. 

TMrdlyi Of presentations of the face. 

Two positions only of face presentation are admitted 
by most modern authors, in common with M. Duges. 
In the fii'st, they all agree, the forehead is dkected to- 
ward the left ihum and the cliin toward the right. In 
the second, the position of the face is reversed, the fore- 
head being toward the right ilium and the chin toward 
ih^ left. 

According to the nomenclature of face presentation, 
usually adopted, the chin {menttim) is made the rela- 
tive point, determining both the position and its name. 
Thus, we have seen, that the first position is denomina- 
ted the 7'i^ht mento-iliac, and the second, the left mento- 
iliac, by M. Cazeaux, in his expose of the views of MM. 
Nsegele and Dubois ; and this nomenclature is ratified by 
M. Moreau. But the unity of Duges's classification, in 
which all the positions of the fetus, in every kind of 
presentation, are regulated by the relations of the back, 
requires us to look to the situation of the forehead 
rather than of the chin, in framing our nomenclature of 
face presentation. I propose, therefore, to call the first 
position of the face its left fronto-iliac^ and the second 
its right fronto-iliac. 'Let it be here observed that M. 
Duges bestowed no other names upon any of his posi- 



234 SPECIAL PHENOMENA OF SECOND STAGE. 



tions than those of then' ordinal numbers, except upon 
vertex positions, to which he appHed the nomenclature 
of Capuron — being apparently more occupied with 
things than names, in which respect he set an example 
worthy of our imitation. To prevent the tiresome repe- 
tition of the same word, it is, however, not improper to 
have more names than one for the same thing, and it is 
with this view that I shall attempt to make out a com- 
plete nomenclature of positions. 

Fourthly and fifllily; Of 'presentations of the right 
and left shoidders. 

The two shoulder presentations may be advantage- 
ously considered in connection. To each of these be- 
long two positions, in the first of which the back of the 
fetus and the arm proper {humerus) are directed forward, 
while the forearm and head are toward the sacrum of 
the mother. But in this first position the head of the 
child is situated over the left ihac fossa, and the nates 
over the right, if the right shoulder present, and vice 
versa if the left shoulder present; while in both pre- 
sentations, the inferior extremities, folded upon the 
abdomen, are contained in the posterior part of the 
uterus. In the second position of either shoulder pre- 
sentation, the back and arm of the fetus are directed 
posteriorly, while the forearm and hand are toward the 
pubes of the mother. The head is over the right ihac 
fossa, and the nates over the left, if the right shoulder 
present, and vice versa, if the left shoulder present; while 
in both, the abdomen and inferior extremities are con- 
tained in the anterior part of the uterus. In harmony 
with our governing principle, I propose to designate the 



PRESENTATIONS AND POSITIONS. 235 



first position of both shoulder presentations, scapulo- 
puhicy and the second of both, scapido'Sacral. Let the 
young student fecundate his mind, producing what may 
be called an ideal gestation, and ponder upon the rela- 
tions of the fetus to the uterus and pelvis in these posi- 
tions, until he has a vivid conception of them, else he 
cannot comprehend them, or follow me in the comparison 
which I shall next make between M. Duges's arrange- 
ment of them and that of other authors. 

M. Moreau establishes his positions of the shoulders 
by the direction of the acromion process of the scapula, 
which he makes the relative point of the fetus. Thus, 
in his first position of both shoulders, the acromion is 
directed toward the left side of the pelvis, the head be- 
ing toward the left ihac fossa, and the axilla and base 
of the thorax toward the right iliac fossa, which is his 
left acromio-iliac position. In his second position of 
both shoulders, or jnght acromio-iliac, the situation of 
the acromion, head, axilla, and base of the thorax is re- 
versed, viz., the acromion and head look toward the 
right iliac fossa, and the axilla and base of the thorax 
toward the left. M. Cazeaux agrees with M. Moreau in 
this arrangement of shoulder positions, differing from 
him, as we have seen, only as to their nomenclature, 
calling the first position of either shoulder its left cef halo- 
iliac, and the second, right cephalo-iliac. Such also is 
the arrangement of Madam_e Lachapelle, in her " Nou- 
velle nomenclature des Positions du Foetus" (1). 

According to the arrangement of these authors, it is 
evident that the numerical position of one shoulder is 

(1) Pratique des Accouchemens, Premier Memoire. 



236 SPECIAL PHENOMENA OF SECOND STAGE. 



totally unlike the corresponding position of the other, 
in regard to the most important relations, practically 
considered, of the child's body to the mother ; for in the 
fivBt position, for example, of the riglit shoulder, the ab- 
domen and inferior extremities of the child are contain- 
ed in the posterior portion of the cavity of the uterus, 
while in this same position of the left shoulder, its ab- 
domen and inferior extremities are situated anteriorly. 
Now, the most important inquuy, in any case of shoul- 
der presentation, is, where are the inferior extremities to 
be found, because in the operation of turning, they are 
to be seized and brought down through the vagina. 
The method of operating is also modified by the situa- 
tion of these extremities, and the operation itself is 
much more easily performed where they are contained 
in the anterior, than where they are in the posterior, 
part of the uterus. The operative procedure, apphcable 
to the first position of either shoulder, is not, therefore, 
apphcable to the same, but to a different position of 
the other shoulder. It appears to me that this is calcu- 
lated to produce confusion and perplexity ; I know, in- 
deed, that it is, from actual trial of it. No such objec- 
tion apphes to Duges's arrangement of shoulder posi- 
tions, which is as natural as it is easily remembered. 
In the first position of both shoulders, the abdomen and 
inferior extremities of the child are directed toward the 
loins of the mother; in the second position of both, 
they are toward the anterior parietes of her abdomen. 



VERTEX PRESENTATIONS. 237 



CHAPTER XIV. 

THE ^MECHANISM, DIAGNOSIS, AND PEOGNOSIS OF 
YEHTEX PRESENTATIONS. 

Mechanism. 

In order that the head may enter and pass through 
the pelvic canal, several conditions, particularly enumer- 
ated by M. Capuron, are requisite. Among these there 
is one, which may be said to be so essential that it is, 
in fact, the principle that governs all the movements 
of the head during its transition. It may be thus sta- 
ted : The axis of the head must be brought parallel 
successively with the axis of the superior and inferior 
strait of the pelvis, that is, its poles, the occiput and 
cliin, must be placed, as nearly as may be, in these ima- 
ginary lines. 

If this principle be rightly apprehended, it affords a 
key to aU the mechanical phenomena of labor, as far as 
the head is concerned, not only in vertex, but, also, in 
nates and face, presentations. The necessity of this 
parallelism between the axis of the head and the axes 
of the straits, arises hence, that it is only when so placed 
that the head can offer its smallest diameters to the 
pelvic canal. 

This most essential condition, or principle, as I have 
ventured to call it, does not appear to have been well 
understood by many writers, I had almost said by any. 



238 SPECIAL PHENOMENA OF SECOND STAGE. 



except Capuron. Thus, Dr. Dewees mentions^ among 
other circumstances whose concurrence is necessary to 
propitious childbirth, favorable situation of the head, 
" or, in other words, the great diameter of the child's 
head must constantly correspond with the great diame- 
ter of the pelvis " (1). By the great diameter of the 
head. Dr. D. means, with us, the occipito-frontaJ, at least 
such is Baudelocque's use of the term, whom he closely 
follows, and therefore the object, according to him, of 
all the mutations the head suffers during its passage, is 
to find room for this diameter — an idea, which, as I 
shall hereafter show, pervades and vitiates the account 
which nearly all the British writers give of the mechan- 
ism of labor. 

M. Duges describes the mechanism of the first and 
second positions of the vertex in conjunction, under the 
common denomination of occipito-anterior positions, and 
that of the third and fourth, as occipito-posterior posi- 
tions. But the unitiated in the mysteries of obstet- 
rical science will be less apt to get bewildered, by having 
the attention directed to the several positions, one by 
one. Nor need this make their studies tedious or irk- 
some, for it will be found that, if the first position be 
mastered, but little remains to be learned with regard to 
the second; and that when the third is understood, the 
fourth is soon dispatched. 

1. Mechanism of the first or left occipito-acetahilar 
position of the vertex. 

In this position, the occiput corresponds with the 

(1) Midwifery, fifth edition, p. 222. 



VERTEX PRESENTATIONS. 239 



left acetabulum, the forehead with the right sacro-iliac 
symphysis, the sagittal commissure is in the direction 
of the left obhque diameter of the superior strait ; the 
posterior fontanel is forward and toward the left, the 
anterior is backward and toward the right. Previous to 
the rupture of the membranes and the occurrence of 
strong expulsive contractions, the head of the fetus is 
but slightly flexed upon the breast, and its diameters 
have nearly the following relations with those of the su- 
perior strait, viz., the occipito-frontal diameter is paral- 
lel with the left oblique diameter, and the biparietal is 
parallel with the right obhque diameter. The great or 
occipito-frontal circumference is, of course, parallel with 
the boundary of the superior strait. 

This situation of the head is not favorable to its en- 
gaging in the superior strait, for it offers a diameter (the 
occipito-frontal) to the left oblique diameter of the strait, 
which is too great, when the diminution of available space, 
by the soft parts of the pelvis and the walls of the ute- 
rus, is taken into consideration. Accordingly, when the 
uterus assumes strong expulsive contractions, and the 
head is urged toward the entrance of the pelvis, the first 
step (1) of the mechanism of labor commences, which 



(1) It is customary with French writers to divide the mechan- 
ism of labor into several distinct parts, for the purpose of more 
methodically describing the process. These divisions they denom- 
inate temps (times), a word which could hardly be adopted by us for 
such a purpose. The word, stages, would perfectly convey the 
same idea, and might be more agreeable to a critical ear than 
" steps," which I employ ; but the appropriation of it, by all Bri- 
tish and American writers, to the threefold division of the entire 
function of parturition, forbids its application to the different evo- 



240 SPECIAL PHENOMENA OF SECOND STAGE. 



comprises the flexion and descent of the head to the bot- 
tom of the iJclvie excavation. Flexion of the head 
causes the occiput to descend, while the forehead rises, 
and consequently the cervico-bregmatic diameter takes 
the place of the occipito-frontal, while the biparietal 
diameter remains as before. Two of the small diam- 
eters of the head, the cervico-bregmatic and biparie- 
tal, are thereby brought parallel with the oblique diam- 
eters of the pelvis, and its lesser circumference is 
parallel with the circumference of the pelvic canal, while 
its axis is parallel with the axis of the superior strait. 
The essential condition, above adverted to, is then com- 
plied with, and the head is prepared to enter the 
pelvis. 

The flexion of the head is doubtless caused by the 
resistance of the superior strait, aided by the cervix 
uteri, which, although it may be considerably dilated, 
does not at once allow the head to engage in its orifice. 
To understand how this resistance produces flexion, it is 
necessary to observe that the head forms a lever by its 
articulation with the spine ; and that in consequence of 
the articulation being nearer the occipital protuberance 
than the chin, the occipital arm of the lever is shorter 
than the mental arm. Let it be observed, moreover, 
that the power, exerted upon the body of the child by 
the contractions of the uterus, is transmitted to the 
head through the medium of the spine; and it is easy 
to see that the resistance being equal at both extremi- 
ties of the lever, the occiput must descend, because it is 



Intions of the meclianism, which is itself but a part of the pheno- 
mena of the second sta^e of labor. 



« 



VERTEX PRESENTATION. 241 



nearest the spine. This may be illustrated by a very 
simple experiment: lay a foot ruler on the table, and 
push against it with the point of the finger opposite the 
figure six, which is its middle; the ruler is forced to 
move against the resistance of the air and friction of the 
table, and both extremities move with equal pace. Push 
next nearer one extremity than the other, and the pace 
of this extremity will be quickened in proportion to the 
nearness of the finger to it, causing it to advance before 
the other. As the occiput descends, the chin mounts up 
toward the breast of the child, that is, flexion takes place. 
Prepared by its flexion, the head descends into the 
pelvic excavation, moving in the direction of the axis of 
the superior strait until its further progress is arrested 
by the sacrum, against which the vertex impinges. At 
this time, it is evident, that although the head fully 
occupies the pelvis, and the right parietal bone, which 
is anterior, is felt considerably below the symphysis pu- 
bis, the vertex is still directed toward the sacrum, and 
the sagittal commissure is placed so far posteriorly that 
it can only be reached hy introducing the finger deeply 
and curving it forward. 

/Second step — rotation. — Arrived at the bottom of the 
pelvis, the hand is forced to execute a rotatory move- 
ment, the occiput advancing from left to right and for- 
ward, toward the S3^mphysis pubis, under which it is 
finally placed. This movement is sometimes executed 
with such facility as makes it difficult to be traced; at 
other times, so tediously that it is tiresome to w^atch it. 
Not unfrequently when the rotation is carried so far as 
to bring the occiput behind the left ischio-pubic ramus, 
it is arrested for a time, the posterior superior part of 
16 



242 SPECIAL PHENOMENA OF SECOND STAGE. 



the right parietal bone projecting meanwhile in the pu- 
bic arch, and the perineum beginning to be distended. 
The inexperienced medical attendant might conclude 
that the birth of the child is at hand, and yet hours 
may elapse before that event; for the posterior fontanel 
is still behind the left ramus of the pubes and ischium, 
and the sagittal commissure still crosses the coccy-pubic 
diameter quite obliquely. 

It is under these circumstances that a swelling is 
apt to form on the liberated portion of the cranial integ- 
uments, viz., over the posterior superior part of the right 
parietal bone, which may continue some time after birth. 
This swelling, called capet succeda7ieum, is formed by 
blood and serum, effused from the vessels of the part, 
in consequence of their engorgement, resulting from ob- 
struction to the return of blood from it ; the obstruction 
consisting in the close constriction of every othei part 
of the head by the osseous and soft parts of the pelvis. 
The swelling of the head increases its protrusion at the 
vulva, and thus tantalizes the accoucheur with the hope 
of speedy release. 

I have said that when the head reaches the inferior 
strait, it is forced to rotate, by which it is to be under- 
, stood that the head could make no farther progress, with- 
out first undergoing this movement. To escape from the 
pelvic excavation, the head must move in the direction of 
its inferior aperture, that is, conformably to the axis of the 
inferior strait, and must offer its lesser circumference to 
this aperture, otherwise there is not room for it to pass. 
But this can be brought about only by its rotation, which 
enables the occiput to emerge first under the symphysis 
pubis, when the axis of the head is placed parallel with 



VERTEX PRESENTATION. 243 



the axis of the inferior strait, and, the essential condition 
being now compHed with, the head is prepared for its 
sortie. Previous to this rotation, the occipito-frontal 
diameter tends toward the left oblique diameter of the 
inferior strait, — the occipito-frontal or great circumfer- 
ence tending toward its plane, — and it is demonstrable, 
with a pelvis and fetal head, that the dimensions it then 
offers cannot pass out, except the head be very diminu- 
tive or the pelvis very capacious; that is, the head 
cannot, except under peculiar favor, clear the inferior 
strait, in a diagonal or oblique position. After rotation, 
the cervico-bregmatic diameter is parallel with the coccy- 
pubic, and the biparietal with the bisischiatic diameter 
of the inferior strait, while the cervico-bregmatic or 
lesser circumference is parallel with its plane; — the 
same small diameters and circumference, with which the 
head entered the pelvis. 

Third step — extension. After the rotation of the 
head, the chin receives the principal force of the uterine 
contractions ; it is consequently depressed, or caused to 
depart from the sternum of the child, against which it 
had hitherto been strongly flexed, and this depression 
of the chin produces the extension of the head. AYhile 
the chin is being depressed, the occiput rises toward 
the mons veneris, and the perineum is put more and 
more on the stretch, until finally the head clears the 
vulva, — the sagittal commissure, the bregma, the coro- 
nal commissure, the nose, mouth and chin appearing 
successively before the anterior edge of the perineum. 
While the distended perineum makes resistance, it is in 
fact but a portion of the posterior wall of the pelvis, and 
bears the head strongly upward toward the mother's 



244 SPECIAL PHENOMENA OF SECOND STAGE. 



abdomen; but as soon as the great circumference of the 
head escapes at the vulva, its natural elasticity causes it 
to retreat rapidly, over the face of the child, and apply 
itself to the anterior part of the neck. 

The cause of the extension movement of the head is 
well explained by M. Cazeaux, to whom we are indebted 
for much light upon the whole subject of the mechani- 
cal phenomena of labor. At the same time that the 
occiput engages in the pubic arch, the shoulders and 
the superior part of the trunk enter the excavation, and 
the flexibility of the trunk enables it to be conformed 
to the axis of the canal, that is, it is curved upon its 
posterior plane. This inflexion of the trunk withdraws 
it from the chin, and is the beginning of the extension 
movement of the head. To comprehend how this move- 
ment is completed, we have only to consider that, from 
the commencement of labor, the uterine contractions 
act both upon the chin and occiput ; but until now their 
force has been chiefly exerted upon the occiput, for a 
reason already given ; and because, moreover, when the 
head is flexed, the occiput is more in the direction of 
the force transmitted through the spine. But when 
the occiput is engaged in the pubic arch, the back of 
the neck is pressed against the posterior part of the 
symphysis pubis, and destroys, by its resistance, all that 
portion of the uterine force that had acted upon the 
occiput. The chin, continuing to receive its share of 
the force, is moved forward, while the junction of the 
back of the neck with the occiput rests stationary un- 
der the symphysis, causing the cervico-bregmatic, cervi- 
co-frontal, and cervico-mental diameters to clear succes- 
..sively the antero-posterior diameter of the inferior strait 



I 



VERTEX PRESENTATION. 245 



During this movement, as M. Cazeaux justly observes, 
the head resembles exactly a lever of the third kind, 
whose prop is the c ervico-occipital point placed under 
the symphysis pubis, the power being at the great occi- 
pital foramen, and the resistance at the chin, augmented 
by that of the perineum. 

Fourth step-external rotation. Shortly after its 
disengagement, the head rotates again, but in a contrary 
direction, the occiput turning toward the inside of the 
left thigh of the mother, and the face toward the inside 
of the right thigh. This movement of the head was 
called by Baudelocque its restitution, because he consid- 
ered its first rotation, in the cavity of the pelvis, a twist 
of the neck, in which the trunk does not participate, 
and when the head is free from constraint, it resumes 
its natural position in relation to the trunk, by the elas- 
ticity of the ligaments of the neck. The correctness of 
this explanation has lately been questioned by M. G-er- 
dy, as we learn from M. Cazeaux, who adopts his views 
of the matter. According to M. Gerdy, the trunk of 
the child participates in the first or internal rotation 
performed by the head, so that the shoulders are simul- 
taneously placed nearly transversely in the pelvis, in- 
stead of remaining oblique as they were when labor 
commenced. They arrive at the inferior strait, in this 
nearly transverse position, the right shoulder being a 
little anterior, where, encountering resistance on account 
of their bisacromial diameter being offered to the small- 
est diameter of the strait, they undergo another rotation 
in an opposite direction, viz.,fi:om right to left, toward the 
symphysis pubis, and the bead, being firee, simply follows 
the movement of the shoulders. This movement of 



246 SPECIAL PHENOMENA OF SECOND STAGE. 



the head he proposes, therefore, to call its external, to 
distinguish it from the internal, rotation it had previ- 
ously executed. The head, therefore, first causes the 
shoulders to rotate, and is in turn rotated by them. 
To M. Cazeaux, however, the head has seemed, in cer- 
tain cases, to execute a double movement, the occiput, 
immediately after its expulsion, turning slightly toward 
the thigh, and after remaining a few seconds in this po- 
sition, experiencing a second movement, caused by the 
rotation of the shoulders. The first of these movements 
appeared to be owing to the untwisting ( detorsion ) of 
the neck. 

One of the arguments adduced by M. Gerdy, in 
favor of his theory of external rotation, it will be found 
difficult to controvert, viz., the fact that, instead of 
turning toward the left thigh, the occiput sometimes 
continues to look toward the pubes for a few moments^ 
or until there is a recurrence of efficient uterine con- 
traction, and then revolves toward the right, — the in- 
terval or first rotation being continued, and the child 
being expelled under a long spkal movement. I have, 
on several occasions, distinctly observed this phenome- 
non, and it is not possible, I think, to reconcile it with 
the theory of Baudelocque. 

Fifth step — extrication of the shoulders, etc. 

The shoulders, having entered the excavation and 
performed their rotation coincidently with the restitution 
of the head, next undergo a movement preparatory to 
their release. Before describing this, it is proper to 
observe that the rotation of the shouklers may be com- 
plete or incomplete, that is, the right shoulder may be 
placed behind the symphysis pubis, as Madame Boi- 



VERTEX PRESENTATION. 247 



■vin(l) and others describe, or under the right ischio- 
pubic ramus, as M. Cazeaux affirms that it most usually 
is. In either case, the shoulder that is anterior (the 
right), having but a short distance to travel, makes its 
appearance first at the vulva, when it remains station- 
ary, being pressed against the pubes, -while the left 
shoulder sweeps over the inferior part of the sacrum, 
the coccyx, and perineum, and is disengaged first or 
along with the right. During this movement, it is evi- 
dent the child's body is strongly curved upon the side 
that is anterior — its right side — to adapt it to the 
curvature of the pehdc excavation. 

The hips easily follow the shoulders, executing, if 
they are large, the same movement: ordinarily, how- 
ever, their expulsion and that of the rest of the child is 
so rapid that the mechanism cannot be observed. 

2. Mechanism of the second or right occipito-acetahu- 
lar position of the vertex. 

In this position, the occiput is turned toward the 
right acetabulum, where also the posterior fontanel is 
found, the forehead toward the left sacro-ihac symphysis, 
and the sagittal commissure is in the direction of the 
right oblique diameter of the superior strait. 

The sereral steps of the mechanism are the same in 
this as in the fii'st position : fiexion and descent ^ internal 
rotation^ extension^ external rotation^ extrication of the 
shoulders, etc., follow each other in the same order and 
from like causes. In this position, however, it is the 
left parietal bone that is anterior, which is consequently 

(1) ^lemorial de 1' Art des Accouchemens, p. 223. 



248 SPECIAL PHENOMENA OF SECOND STAGE. 



most easily felt by the finger ; the head rotates from 
right to left, instead of from left to right, to bring the 
occiput under the symphysis pubis ; if the rotation be 
tediously performed, it is upon the posterior superior 
part of the left parietal bone that the cranial tumor is 
formed; and when the head is disengaged, the occiput 
turns toward the right thigh of the mother, while the 
left shoulder appears at the vulva, and is the point upon 
which the right shoulder moves to come out first before 
the anterior commissure of the perineum. 

It is asserted by M. Capuron (1), that the mechan- 
ism of labor, usually executed as easily in this second 
as in the first position, is more liable to be embarrassed 
in consequence of the frequent existence of right ante- 
rior obliquity of the uterus, when the force of its con- 
tractions is directed leftward and backward, and may 
interfere with the flexion of the head, or even increase 
the extension of it, which existed before labor com- 
menced. It may happen, also, he apprehends, that a 
loaded state of the rectum will prove an obstacle to the 
rotation of the head, by hindering the revolution of the 
forehead and face from left to right. These apprehen- 
sions of M. Capuron appear to me to be purely hypo- 
thetical ; certainly, I have met with nothing in practice 
to justify them. Although I have not unfrequently 
encountered second position of the vertex, I am not 
aware that either delay or difficulty could be justly as- 
cribed to it. 

(1) Cours Theorique et Pratique d' Accouchemens, p. 208. 



VERTEX PRESENTATION. 249 



3. Mechanism of the third or right occipito-sacro- 
iliac position. 

This position resembles the first, in that the same 
diameters of the head correspond to the same diameters 
of the pelvis, before any change is made by labor; viz., 
the occipito-firontal to the left oblique, the biparietal to 
the right obhque, and the sagittal commissure crosses 
the pelvis in the same direction. But the relative situ- 
ation of the occiput and forehead is reversed, — the oc- 
ciput being opposite to the right sacro-ihac symphysis, 
and the forehead to the left acetabulum, — and the left 
parietal bone is anterior and most accessible, as in the 
second position. 

The third position may march through its mechan- 
ism by the same steps as the first and second, only one 
of them will be a stride; or an extra step^ altogether 
pecuhar to it and the fourth position, may be requisite, 
and hence the impropriety of confounding these posi- 
tions with the first and second, as M^I. Nsegale and 
Dubois have done. 

Flexion and descent of the head are the same in the 
thu'd position as in the first and second; the peculiari- 
ties of it are connected with, or consequent to, the ro- 
tation of the head, which will, therefore, claim our chi^f 
attention. This movement may be accomplished in 
two modes ; first, the occiput may be thrown into the 
hollow of the sacrum: or, second, it may be convej^ed 
under the symphysis pubis. 

First. Rotation of the occiput into the holloiu of the 
sacrum. — This takes place subsequently to the descent 
of the head, and when it is achieved, the occiput is 
lodged in the hollow of the sacrum and the forehead he- 



250 SPECIAL PHENOMENA OF SECOND STAGE. 



hind, not under, the symphysis pubis. It is then the 
occipito-frontal diameter which occupies the antero-pos- 
terior dimension of the excavation, where there is space 
enough to accommodate it, but the antero-posterior 
diameter of the inferior strait is not large enough to 
allow it to pass out. The axis of the head, moreover, is 
yet nearly parallel with the axis of the superior strait; 
the head is not, therefore, prepared to pass the inferior 
strait, the essential condition^ so often referred to, not 
having been complied with. An extra flexion of the head 
now commences, which is the extra step alluded to, un- 
der which the occiput is depressed, while the forehead 
mounts higher behind the symphysis pubis, until the 
occiput emerges before the anterior edge of the perine- 
um. This extra flexion establishes such relations as 
aUow the head to be delivered, for the cervico-bregmatic 
diameter is now nearly parallel with the coccy-pubic, 
and the biparietal with the bisischiatic : while the axis 
of the head is brought more nearly into correspondence 
with the axis of the inferior strait. 

After the emergence of the occiput in this, as in the 
first, position, extension begins; but here its prop is chang- 
ed to the perineum, instead of the under edge of the 
symphysis pubis, for the posterior inferior part of the oc- 
ciput rests on the perineum, while successively the breg- 
ma, the forehead, nose, mouth, and chin come out under 
the pubic arch. Sustaining, as it does, the force of this 
extension movement, it is no wonder that the perineum 
is much more liable to be ruptured in this position of 
the vertex. Of this liability there can be no doubt: it 
is distinctly admitted by many writers, and by none 



VERTEX PRESENTATION. 251 



more empliatically than by Dr. Merriman (1), who gives 
to such a position the foremost place in his thkd order 
of difficult parturition (Dj^stocia Perversa), and remarks 
concerning it, " It is necessary to pay particular atten- 
tion, to prevent a laceration of the perineum; for the 
external parts are excessively stretched when the head 
passes in this dkection. Even women," he continues, 
" who have borne many children, have had the perineum 
lacerated under the circumstances of this kind of pre- 
sentation." 

The cause of the extraordinary distention of the pe- 
rineum, and of its exposure to rupture, does not appear 
to have been very clearly perceived by writers, who usu- 
ally ascribe it to the forehead not fitting the pubic arch 
so well as the occiput, and leaving consequently an un- 
occupied space which must be compensated by increased 
dilatation toward the perineum. But it is rather to be 
sought for, I apprehend, in a peculiarity of mechanism 
pertaining to the case under consideration. It has been 
already stated that the head, subsequently to its extra 
flexion, has its axis brought more nearly parallel with 
the axis of the inferior strait than it was before. It 
should be observed, however, that these axes are not, 
and it is not possible that they can be, brought so nearly 
parallel as they are, when, as in the first and second ver- 
tex positions, the occiput is liberated under the symphy- 
sis pubis ; for the thickness of the child's neck (to say 
nothing of the trunk necessarily drawn into the excava- 
tion, before the occiput is disengaged) intervenes be- 

(1) Synopsis of Difficult Parturition, first American, from se- 
cond London, edition, Philadelphia, 181G, p. 57. 



252 SPECIAL PHENOMENA OF SECOND STAGE. 



tween its chin and the sacrum". It is plain, then, that 
the mental extremity of the axis of the head is pushed 
too far forward toward the pubes, and its occipital ex- 
tremity too far backward. The essential condition is 
not, and cannot, therefore, be complied with; and, strictly 
speaking, the cervico-bregmatic diameter is not parallel 
with the antero-posterior diameter of the inferior strait; 
nor does the lesser circumference of the head offer to its 
aperture, but one that is greater, though not so large as 
the occipito-frontal. It is, therefore, the larger circum- 
ference of the head that passes out, together with the 
shifting of the prop of the extension movement, that 
causes greater distention of the perineum, and endan- 
gers its laceration. 

Secondly. Rotation of the occiput toward the pules. 
— In this anterior rotation of the occiput, the head 
takes a stride instead of the corresponding step belong- 
ing to first and second vertex positions, for the occiput 
is brought from the right sacro-iliac junction and depos- 
ited under the symphysis pubis. The effect of this 
movement is first to convert the third into the second 
position, and then to dispose of it as though it had been 
an original second position. There is a great difference, 
in different cases, with regard to the facility with which 
this extensive rotation is executed. In some women, 
especially in such as have borne children before, and 
whose pelves are capacious and parturient powers vigor- 
ous, it may be effected by a few pains, even by a single 
one; while in others, particularly in primiparse, it may 
take place most tediously, — the posterior fontanel mov- 
ing forward during a pain, and retreating as soon as the 



VERTEX PRESENTATION. 253 



pain goes off. This bandying may be so protracted as 
to sorely weary the accoucheur and effectually test his 
patience, as I have many times experienced. 

4. Meclianism of the fourth or left occipito-sacro-iliac 
]}ositioii. 

There is the same resemblance between this and the 
second position, as there is between the third and first, 
in respect to the correspondence of cephalic and pelvic 
diameters, at the commencement of labor, viz., the occi- 
pito-frontal is applied to the right obhque, the biparietal 
to the left oblique diameter, and the sagittal commissure 
crosses the pelvis in the direction of the right oblique 
diameter. But the occiput is toward the left sacro-iliac 
symphysis, instead of toward the right acetabulum, and 
the right parietal bone is anterior and nearest the vul- 
va, as in the first position. 

The mechanism of the fourth position resembles 
that of the third, with only the trivial difference incident 
to its location. The head may be expelled by the route 
of posterior or anterior rotation of the occiput; but if 
by the former, the occiput moves from left to right, in- 
stead of from right to left, as it does in the third posi- 
tion ; and after the escape of the head, it turns toward 
the left nates of the mother (its restitution), instead of 
toward the right nates as it does in the third position. 
If its expulsion is effected by the latter (anterior rota- 
tion), the occiput describes an extensive arc of a circle, 
in marching from the left sacro-ihac junction forward 
and toward the right, instead of moving from the right 
sacro-iliac symphysis forward and leftward, as it does in 
the third position. 



254 SPECIAL PHENOMENA OF SECOND STAGE. 



Having described the two -modes in which rotation 
may take place in the occipito-posterior positions, we 
may next inquire which of these is most conformable to 
the natural mechanism of labor, or, in other words, 
is of most frequent occurrence in childbirth ? 

Baudelocque considered the rotation of the occiput 
into the hollow of the sacrum as by far the most com- 
mon, — so common, indeed, that its anterior rotation is 
but a rare exception, unfortunately, as he thought, too 
rare, seeing it is so much preferable for both mother and 
child (1). And this doctrine was universally accred- 
ited, I believe, until it was controverted by the cele- 
brated Professor Nssgele, of Heidelberg, in Germany, 
who declares that according to his observation, "the 
process tvhidi has heen considered as a regular phenom- 
enon^ is a deviation; and exactly that which has heen 
esteeyned a deviation from the usual course and nde, is 
perfectly regular " (2). He avers that in ninety-six 
cases of the third vertex position, which he observed 
with particular care, the head came through the external 
passage only three times with the face upward or for- 
ward, and that even in these few instances, there were 
circumstances, such as unusual capacity of the pelvis, 
the small size of the head, or its incomplete ossification, 
which seemed to favor such a termination. 

M. Moreau agrees with M. Nsegele on this point, 
candidly avowing that he had, for a long time, concurred 
with Baudelocque; but that his further experience had 
convinced him that Baudelocque mistook the exception 

(1) L'Art des Accouchomens, Tom. I, p. 316. 

(2) Mechanism of Parturition, p. 48. 



VERTEX PRESENTATION. 255 



for tlie rule, and the march of nature in the majority of 
cases for an exception (1). M. Moreau does not, as far 
as I have examined, make any more precise statement 
as to the proportion of cases in which this rotation oc- 
curs : but Dr. Rigby, who appears to have been fully 
imbued with the doctrine of M. Nsegele, by attendance 
on his lectures at Heidelberg, bears testimony to the 
exceeding commonness of it. Dr. Rigby speaks (2) of 
the fourth position, for example, as only a slight modifi- 
cation, occasionally observed, of the first, which, he 
thinks, is not detected so frequently as it really occurs, 
owing to its changing into the common (first) position 
at an early period of labor. He concurs with Professor 
Nsegele in reckoning the third as the usual position, 
where the occiput is turned toward the right side of the 
pelvis ; but that as labor progresses, the occiput forsakes 
the right sacro-ihac symphysis and, coming forward, 
assumes its place in the second position. 

My own observation has fully satisfied me that the 
anterior rotation of the occiput is more common than 
the posterior, although, hke M. Moreau, I once thought 
differently, — too credulously relying on the authority of 
others, particularly of Baudelocque and Dewees. 

While under the influence of this erroneous opin- 
ion, I met with a good many cases of occipito-posterior 
positions, in which anterior rotation was effected ; but 
the efficiency, I verily believed, belonged to me, and 
not to nature, because I labored assiduously to promote 
it, after the manner recommended by Baudelocque and 



(1) Traits Pratique des AccoTicliemens, Tom. II, p. 82. 

(2) System of Midwifery, chap. Mechanism of Parturition. 



256 SPECIAL PHENOMENA OF SECOND STAGE. 



Dewees. To do this is, indeed, -reckoned by the latter 
so important, that he holds the man " incompetent to 
practice midwifery, in its best manner, who cannot detect 
and change this malposition of the head, and thus 
abridge, sometimes by several hours, the misery and 
pain of his patient " (1). I have since experimentally 
allowed nature to take her course, in a considerable 
number of such cases, and I find that the desired muta- 
tion is generally accomplished about as well without as 
with my assistance; and that when it is being executed 
slowly and diificultly, as when the occiput comes for- 
ward during the pains and retreats in the intervals, it 
will be vain to attempt to turn the head round by the 
pressure of one or two fingers. After wearying myself 
by fruitless efforts of this kind, I have sometimes alto- 
gether desisted, and nature, though she would not be 
hastened, has done the work in such time as was most 
pleasing to herself 

In subscribing to the doctrine of the greater fre- 
quency of anterior rotation, I must not be understood 
to agree with Nsegele and Rigby in the opinion, that it 
has really taken place in almost every case, where the 
vertex is found in the second position ; that it is, in 
fact, as the latter states (2), the regular commencement 
of labor in third positions, which are, according to them, 
so much more common than original second positions. 
I have expressed my doubt of the accuracy of this 
statement, in the preceding chapter, and I may here 
add that I cannot believe, with Dr. lligby, that third 
positions have been so generally overlooked or mista- 

(1; Midwifery, p. 255. (2) Op. et Cap. cit. 



VERTEX PRESENTATION. 257 



ken, as he imagines ; at all events, I cannot suppose 
that they have so strangely eluded my observation and 
imposed themselves upon me as second positions. And 
yet this must have happened, if I have not met with 
many more cases of second than third positions. 

No part of the mechanism of vertex presentations 
has given rise to such diversity of views among authors, 
as the rotation of the head. This has been not only 
variously described, but differently accounted for: and 
I have, therefore, deferred discussing its etiology, until 
I had furnished what I consider a correct description of 
it, in all the vertex positions, in order that I might in- 
stitute a more extended examination of these conflicting 
opinions and statements than would have been compat- 
ible with the merely descriptive part of the subject. 

The first view of the rotation of the head that will 
claim our attention is that of the deservedly eminent 
Dr. Smellie, — a practitioner and teacher of midwifery 
in London, a century ago. His account of the matter 
is entitled to the more respect because it has passed 
current with British writers ever since, with the excep- 
tion of a small detachment, which has recently been im- 
pregnated with the doctrines of the German school, 
presently to be examined. 

" When the head first presents itself at the brim of 
the pelvis," says Dr. Smellie, " the forehead is to one 
side, and the hindhead to the other, and sometimes it 
is placed diagonal in the cavity: thus the widest part of 
the head is turned to the widest part of the pelvis, and 
the narrow part of the head, from ear to ear, apphed to 
the narrow part of the pelvis, between the pubis and 
sacrum. The head being squeezed along, the vertex 
17 



258 SPECIAL PHENOMENA OF SECOND STAGE. 



descends to the lower part of the ischium, where, the 
pelvis becoming narrower at the sides, the wide part of 
the head can proceed no further in the same Hne of 
direction ; but the ischium being much lower than the 
OS pubis, the hindhead is forced in below this last bone, 
where there is least resistance. The forehead then 
turns into the hollow at the lower end of the sacrum, 
and now again the narrow part of the head is turned 
to the narrow part of the pelvis. The os pubis being 
only two inches deep, the vertex and hindhead rise up- 
ward from below it ; the forehead presses back the coc- 
cyx, and the head, rising upward by degrees, comes out 
with a half round turn, from below the share bone : the 
wide part of the head being now betwixt the os pubis 
and the coccyx, w^hich being pushed backward, opens 
the widest space below, and allows the forehead to rise 
up also with a half round turn, from the under part of 
the OS externum " (1). 

On attentively perusing this description, it will be 
seen that no account is taken of the flexion of the head, 
as it descends in the pelvic excavation, but, on the con- 
trary, it turns upon the supposition that the head is 
perfectly inflexible, and is squeezed along until its longi- 
tude ( occipito-frontal diameter) takes up its position 
alongside with the transverse or obhque diameter of the 
inferior strait. Now, there is no part of the mechan- 
ism of labor, which may be verified more easily than the 
flexion of the head ; the proof of it is obtained by ob- 
serving the depaiture of the posterior fontanel from 



(1) Theory and Practice of Midwifery, fifth edition, London, 
1766, Vol. L p. 87. 



VERTEX PRESENTATION. 259 



the side of the pelvis, and its gradual approach toward 
the middle. The flexion will be slight or considerable 
according as the head is small or large, but a degree of 
it takes place in every case of labor, and I have con- 
stantly observed that, in cases of disproportion between 
the head and pelvis, the posterior fontanel becomes 
the most dependent part, and is brought near the cen- 
ter of the pelvic cavity. K this observation be true, I 
hardly need say that it is the cervico-bregmatic, instead 
of the occipito-frontal, diameter of the head, which sinks 
obliquely to the bottom of the pelvis; and, as this is one 
of the small diameters of the head, it follows that rota- 
tion is not needed to put it in possession of the greater 
space that may be found beneath the symphysis pubis. 
Nor, after rotation has taken place, is it true that the 
" wide part of the head " is between the pubes and coc- 
cyx : it is still the cervico-bregmatic diameter, measu- 
ring no more than the biparietal, which, at the same in- 
stant, occupies the transverse diameter of the inferior 
strait. 

From what has been said, it is evident that, while 
Dr. SmelHe had a just notion with regard to the time 
and manner of the head's rotation, he was unacquainted 
with the cause and object of it. It has been already 
stated that the doctrine of Smellie on this subject is, 
with a specified exception, the doctrine of British wri- 
ters generally, and to show how firmly it is ingrafted 
upon them, I need only refer to one of the most recent 
and highly valued of this class, — the younger Rams- 
botham. In describing the fetal head. Dr. Ramsbotham 
mentions only three diameters, viz., 1. The long diam- 
eter, the face not being included, which is our occipito- 



260 SPECIAL PHENOMENA OF SECOND STAGE. 



frontal: 2. The short diameter, from one parietal boss 
to the other: 3. The diameter from the vertex to the 
chin ( occipito-mental ). The first he reckons four and 
a half inches, the second three and a half, and the 
third five and a half, but capable of being lengthened 
to seven inches. In Plate V, Figure 19, he gives a 
view of the vertex, with two oval lines surrounding it, 
one being an inch greater in its long diameter than the 
other. The smaller oval is our occipito-frontal circum- 
ference, — the larger, our occipito-mental circumference. 
Now, the advantage of vertex presentations, according to 
Dr. R., consists in this smaller oval offering itself to the 
pelvic cavity, which leaves a clear superabundant space 
of at least half an inch between the cranial and pelvic 
bones, both in the lateral and conjugate diameters, 
which is generally quite sufficient for the easy passage 
of the head. Having premised thus much of the head, 
he goes on to describe the mechanism of its passage in 
cases of ordinary labor in this wise : " It enters the 
brim with the vertex as the most dependent part, with 
the face to one ilium and the occiput to the other, or 
more commonly with the face looking toward one sacro- 
iliac symphysis, and the occiput behind the groin on the 
opposite side of the body. Descending in this direc- 
tion, it takes full possession of the cavity, and the fore- 
head and occiput impinge respectively on the inner 
surfaces of the tuberosities of each ischium. Since, 
however, in this position, its long diameter is opposed 
to the short diameter of the outlet, — since the tuberos- 
ities of the ischia are unyielding, — and since the long 
diameter of the head exceeds the short diameter of the 
outlet by half an inch, — it is evident that a change in 



VERTEX PRESENTATION. 261 



its relative situation must be made before it can be ex- 
pelled. This alteration is effected by a slight rotation 
of the cranium ; the face is thrown into the hollow of 
the sacrum, the occiput peeps up under the arch of the 
pubes, and the head eventually escapes with the face 
sweeping the sacrum, coccyx, and perineum. This turn 
is produced by mechanical causes, and depends on the 
resistance which the peculiar construction of the pelvic 
bones opposes to the propelling efforts exerted by the 
uterus: — The inner surfaces of the ischia^ somewhat aj)- 
proaching each other as the?/ descend, together ivith the 
spinous processes of the same hones, afford an inclined 
plane along which the head is directed; the hollow of 
the sacrum offers an unoccupied cavity, iuto which the 
face is received, and the arch of the pubes a wide-spread- 
ing sinuosity, through which the occiput insinuates 
itself" (1). 

The above description of the rotatory movement of 
the head agrees perfectly with that of Dr. Smelhe ; the 
same necessity of it is likewise alleged ; but Dr. Rams- 
botham discloses the agency of the inclined planes in 
producing it^ and it is difficult, at least for me, to recon- 
cile their agency with the account which he gives of the 
thing itself By the inchned planes of the pelvis, he 
e^adently means the entire inner surfaces of the ischia, 
approaching each other as they descend ; if, therefore, 
they are operative at all, their influence ought to com- 
mence as soon as the occiput and forehead are made 
to glide upon them, — tm^ning the occiput forward, 

(1) Process of Parturition, second American edition, 1845, 
p. 33. 



262 SPECIAL PHENOMENA OF SECOND STAGE. 



and the forehead backward, so - as to land the former 
under the pubic arch, and the latter in the hollow of the 
sacrum. But according to his own account, when the 
head reaches the bottom of the pelvis, it is yet so trans- 
versely placed that the occiput impinges on the inner 
surface of one tuber ischii, and the forehead on the 
other, the occipito-frontal diameter corresponding to the 
bis-ischiatic diameter of the inferior strait : it is, there- 
fore, as easy to see that the whole of the rotatory 
movement remains to be performed, as it is difficult to 
comprehend how such inclined planes can produce it. 
Other authors, who describe this movement differently, 
but less correctly, can make a better use of their in- 
cHned planes. 

The concluding remark in the last paragraph leads 
me to consider, secondly, the account given by M. Capu- 
ron of the rotation of the head. M. Capuron correctly 
attributes to the lateral walls of the pelvis two planes, 
an anterior and posterior one, whose direction is invert- 
ed, so that while one of the parietal tubers is ghding 
downward and forward upon the former, the diagonally 
opposite frontal boss moves upon the latter, in a contrary 
direction, into the hollow of the sacrum. This revolution 
of the head he calls its spiral rotation, because it takes 
place, as he contends, simultaneously with its flexion 
and descent, after the manner of the turning of a screw in 
its nut, or the horing of a gimUet in a piece of tvood{l). 
This screw-like movement is described by Professor 
Meigs, also, as a part of the regular mechanism of la- 
bor : speaking of the first vertex position, he says, "and 

(1) Cours, etc., p. 103. 



VERTEX PRESENTATION. 263 



the vertex or posterior fontanel glides along down the 
ischiunij repelled by that bone, and dkected by its in- 
clined plane inward and forward, so that it describes a 
spiral line in its descent; and the vertex, which on enter- 
ing the upper strait was directed to the left, is without 
any change of posture of the child's body, turned near a 
quarter or a sixth of a circle, to bring it under the arch 
of the pubis," etc. (1) 

Although I am not sure that I ever observed this 
boring movement of the head, I am bound to admit that 
others have, and to agree, therefore, that it may happen 
as one of the deviations from the natural order. I could 
not own it as the regular mechanism, without supposing 
that my touch has grossly deceived me all my profes- 
sional life. Until I am awakened from this delusion, if 
delusion it be, I venture to suggest that others may not 
unfi-equently have been mistaken, when they imagined 
the head had rotated, presuming that it was the occiput 
they felt, somewhat protuberating under the symphysis 
pubis, when it was really the adjoining portion of one 
of the parietal bones, and a more careful examination 
would have detected the posterior fontanel behind the 
pubic ramus. Such mistakes, it is well known, have 
been committed. 

There is yet another view of this subject, which will 
claim a larger share of our attention than either of the 
preceding, because it is the latest fashion, and on that 
account, if no other, is attracting many votaries. 

According to this, which may be called the German 
view, because it was proposed by the celebrated N^egele, 

(1) Philadelphia Practice of 3Iidwifery, First edition, p. 164. 



264 SPECIAL PHENOMENA OF SECOND STAGE. 



of Heidelberg, and is extensively diffused in Germany, 
— the head experiences but a shght rotation in the pel- 
vis — so slight that it makes its escape, at the inferior 
strait, in nearly the same oblique position, which it had 
on entering the pelvis. 

In explanation of this doctrine, it will be fair to al- 
low Professor Nsegele, its propounder, to narrate what 
befalls the head, when it reaches the inferior strait, 
where it arrives, according to him, without having un- 
dergone the least flexion, — for he says sometimes the 
posterior fontanel is lowest, sometimes the anterior. 
Speaking of the first position, he says : " By continued 
pressure of the uterine contractions, the posterior fonta- 
nel at last gradually moves itself by shght degrees, re- 
peated at equal intervals, in a direction from left to 
right (frequently more or less from above downward), 
and the occipital bone advances from the side of the 
pelvis under the arch of the pubis. It is not, however, 
the center of the occiput that advances under the pubal 
arch, but the head approaches the os externum, with the 
posterior and superior part of the right parietal bone, 
and remains in this position until it has passed through 
the outlet of the pelvis with the greatest circumference 
which it opposes to it, where it then turns itself with 
the face completely toward the right thigh of the 
mother. ¥/hen the head is engaged in the external 
passages, and we trace the saggittal suture with the 
point of our finger from the posterior fontanel, it wiU, 
during examination, take the direction of a line 
drawn from the left descending ramus of the pubis to 
the right ascending one of the ischias ; it is in short the 
posterior and upper part of the right parietal bone which 



VERTEX PRESENTATION. 265 



passes first through the os externum " (1). With re- 
gard to the tMrd position, which, as we have seen, he 
considers next in fi.^equency to the first, he observes, 
" As soon as the head is engaged in the cavity of the 
pelvis, the great fontanel turns toward the descending 
ramus of tbe left os ischium, and both can be felt at an 
equal hight as to each other. As soon as the head ex- 
periences the resistance which the inferior part of the 
pelvic cavity opposes to it, or, in other words, the oblique 
surface which is formed by the lower end of the os sa- 
crum, by the os coccygis, the ischiatic ligaments, etc., 
by which it is compelled to move from its position back- 
ward, in a direction forward, it turns by degrees with its 
great diameter into the i^ight (2) oblique diameter of the 
pelvic cavity ; that is, the posterior fontanel is directed 
to the right foramen ovals, and as the head approaches 
nearer and nearer to the inferior aperture, it is the pos- 
terior and superior quarter of the left parietal bone, 
which is felt in the cavity of the pelvis, opposite to the 
pubal arch ; so that when the point of the finger is in- 
troduced under and almost perpendicular to the sym- 
physis pubis, it touches nearly the middle of the supe- 
rior and posterior quarter of the left parietal bone ; and 
iliis is precisely the part^ as the head advances further, 
which first distends the labia, ivith tvhich the head fi.rst 
enters the external passage, and the spot upon which the 
swelling of the integument forms itself'^ (3). 



(1) Mechanism of Parturition, p. 22. 

(2) Substituted for left, — Nsegele's name for this diameter, 
extending from left sacro-iliac symphysis to right acetabulum. 

(3) Op. cit. 



266 SPECIAL PHENOMENA OF SECOND STAGE. 



Dr. Higby, in his Midwifery, does but repeat Pro- 
fessor Nsegele's description, and appears to be fully per- 
suaded of its accuracy. Dr. Churchill's entire account 
of the mechanism of labor is confessedly taken from the 
great German, and he is to be understood as subscribing 
to the correctness with which this part of it is dehnea- 
ted; unless, indeed, the rotation of the head be one of 
the few doubtful points, referred to by him, which he so 
confidently predicts will be cleared, as his experience 
increases, and his ability to observe accurately is devel- 
oped. Such appears to be the import of the following 
remarkable declaration : " The more closely his (Nsege- 
le's) opinions have been tested by experience and care- 
ful observation, the more clear does their correctness 
appear; and if on one or two points, a doubt yet remains 
on our own minds, we are ready to believe the cause to 
be in our deficient experience, or incorrect observa- 
tion " (1). Dr. Maunsell, although he avows his adop- 
tion of the opinions of Nsegele, from a conviction of their 
general correctness, does not go the length of abohshing 
the complete rotation of the head, but defers it to the 
eleventh hour. "As the head descends," says he, "the 
face turns somewhat into the hollow of the sacrum, and 
the vertex approaches the symphysis pubis. It is, how- 
ever, the parietal bone which first escapes, and the ver- 
tex does not reach the anterior central line until in the 
very act of heing expelled from the outlet " (2). 

Having fully stated the opinions of others on the 



(1) Theory and Practice of Midwifery, p. 187. 

(2) Dublin Practice of Midwifery, New York edition, with 
notes and additions, by Professor Grilman, p. 37. 



VERTEX PRESENTATION. 267 



subject, I feel bound to declare my own unshaken faith 
in the reality of such a rotation as I have ascribed to 
the head, in the account already given of the mechanism 
of labor. This faith does not repose upon authority 
only, but, as I flatter myself, upon careful and repeated 
observation. Like Nsegele, I have in numerous instances 
watched the different evolutions of labor, with my finger, 
for hours, now on a fontanel, and anon on the commis- 
sures, and if I have not almost uniformly verified the 
com])lete rotation of the head, I have as yet learned 
nothing in midwifery. When, in a first position of the 
vertex, the posterior fontanel is, at a certain stage of 
labor, plainly felt behind the left obturator foramen, 
while the lambdoidal commissure is to the left of the 
symphysis pubis, and the sagittal crosses the vagina 
obUquely from above downward and from left to right, 
but in the further progress of labor, the lambdoidal is 
brought completely forward, so that its branches cross the 
rami of the pubes equidistantly from the symphysis, and 
the sagittal runs vertically, parallel with the genital fis- 
sure, while the posterior fontanel is to be felt on the 
same line, — when, I say, all this is plainly and nearly 
invariably felt, the conviction must be riveted upon the 
mind of the observer, that tlie Jiead does verily completely 
rotate. Such is my experience — or, if it prove unreal, 
my dream, for more than twenty years. 

Is it inquired how are w^e to account for the con- 
flictmg experience of Professor Nsegele ? I answer, I 
do not know. It would be presumptuous in me to 
charge him with having mistaken the exception for the 
rule ; but the fact is unquestionable, that the head is 
sometimes expelled obliquely ; how often, is not perhaps 



268 SPECIAL PHENOMENA OF SECOND STAGE. 



well ascertained. Madame Lachapelle observes (1), 
that the head sometimes passes out obliquely, and clears 
the vulva, without experiencing any horizontal rotation, 
preserving the direction it had while in the pelvic ex- 
cavation ; but, she adds, " it passes with gi'eater diffi- 
culty," — showing that such a passage is an aberration 
from the normal route, and that nature does not delight 
in such obliquities. 

The question of the degree of the head's rotation, it 
is evident, must be decided by observation alone, and 
to such an arbitrament I freely commit it; yet there is 
one evidence of the truth of his opinion, so frequently 
adduced and so much relied on by Professor Nsegele, 
that it ought not to be excluded from notice. I allude 
to the point of the head upon which the caput siicceda- 
neiiin is formed, in cases of Hngering and difficult partu- 
rition. The admitted fact, that the posterior superior 
part of the parietal bone that is anterior, is the point 
in question, proves indeed that this part of the cranium 
is long opposite to the arch of the pubes, where it is free 
from the compression to which the rest of the head is 
subjected ; but does not prove that this part is first ex- 
pelled, or that the head does not rotate, so as to place 
the occiput eventually under the symphysis pubis. The 
cranial sweUing, it has been shown, occurs in cases of 
tedious rotation, and proves no more than that the head 
was obliquely situated while it was forming. 

From what has been said, it appears that although 
obstetrical writers have differed as to the manner and 
purpose of the head's rotation, they agree generally in 

(1) Pratique, etc., Deuxieme Memoire. 



VERTEX PRESENTATION. 269 



representing the inclined planes of the pelvis, in one 
way or another, as its cause. But M. Cazeaux contends 
that too much importance has been attached to these 
planes; and that, as in fact the head does not usually ro- 
tate, until its expulsion is so nearly completed that the 
perineum is pressed on, they really exert no influence 
whatever. He endeavors to explain the movement in 
question irrespectively of these planes, by considering 
only the manner in which two forces, viz., uterine con- 
traction and the resistance of the pelvic walls, act on 
the head. Supposing, for example, that the head is 
placed in the third position, the uterine contractions, 
being exerted in the direction of the axis of the superior 
strait, cause the occiput to descend downward and back- 
ward, until it is arrested by the inferior part of the 
sacrum and the soft parts of the outlet, when it is com- 
pelled to change its course. The resistance it meets 
with may, he thinks, be represented as a force, whose 
dh'ection is perpendicular to the surface it encounters, 
and which, therefore, being applied to the right posterior 
part of the head in contact with this surface, tends to 
move this part of the head forward and somewhat up- 
ward. The occipital extremity of the head thus acted 
upon by two forces, one urging it downward and back- 
ward, the other forward and upward, moves in the 
direction of their remltant^ viz., downward and forward 
and to the right (1). 

This theory of M. Cazeaux is certainly ingenious, 
but it may be doubted whether it will enable us to ex- 
plain all the phenomena, which are observed in connec- 

(1) Traite, etc. Phenomenes Mecanicque du Travail. 



270 SPECIAL PHENOMENA OF SECOND STAGE. 



tion with the rotation of the head. So far from explain- 
ing the rotation of the occiput into the hollow of the 
sacrum, in third and fourth vertex positions, for exam- 
ple, it is altogether opposed to such an occurrence, 
which, by the by, is denied by M. Cazeaux, who con- 
tends that when anterior rotation fails to take place, the 
head is always expelled obliquely. But the posterior 
rotation is too well attested to be successfully denied. 
Again, it would appear that if the head is controlled in 
its movements by the forces assigned, abstracted from 
all other influences, when the forehead is found in the 
right posterior part of the pelvis, as it is in the first po- 
sition, it ought, in obedience to the same resultant, to 
revolve forward and convert a first into a fourth position. 

To express my own views of the subject, I would 
say that the rotation of the head is produced by a num- 
ber of concurring circumstances. In the first place, the 
obstacle offered by the inferior strait to the head's fur- 
ther progression, without a change of its position, may 
be mentioned as one circumstance, and of such impor- 
tance that if it do not exist, as, for example, where the 
head is very small or the pelvis unusually capacious, 
rotation does not take place, but the head is expelled 
obliquely. In describing the mechanism of labor, it was 
stated that the head is forced to rotate by this circum- 
stance; in making such a statement, however, it was not 
intended that there is anything in the mere arrest of 
the head that determines its rotation rather than any 
other movement, but that the descent of the head being 
checked, it is under the necessity of moving in some 
other way, if it move at all. 

In the second place, impelled by the uterine con- 



VERTEX PRESENTATION. 271 



tractions, the head is invited to rotate, by the peculiar 
structure of the pelvis, its incHned planes offering suitable 
surfaces for its most prominent convexities to glide 
upon. To be convinced of this, one has only to take a 
female pelvis, and place a fetal skull within it, in the 
first or second position, as it is after its descent is com- 
pleted. Having satisfied himself that the skull cannot 
be pushed through the inferior strait, while diagonally 
situated, let him gradually rotate the occiput toward the 
symphysis pubis, and he will see that while the parietal 
bosses easily revolve upon the anterior inferior inchned 
planes, one of the frontal bosses revolves, with equal 
facility, upon one of the posterior superior planes. If, 
now, the fetal skull be placed in the third or fourth 
position, it will be manifest that, when it is at the bot- 
tom of the pelvis, the forehead is entirely above the 
anterior planes of the pelvis, and the occiput below the 
posterior, and consequently the structure of the pelvis 
does not favor the revolving of the forehead toward the 
pubes. Nay, not only is such a movement not favored; 
it is positively hindered by the shape of the ossa pubis 
internally. But while, as far as the structure of the 
pelvis is concerned, there is nothing to invite the fore- 
head toward the symphysis pubis, one of the posterior 
superior planes offers it a fit surface to glide upon toward 
the hollow of the sacrum. 

In the third and last place, the head is caused to 
rotate rather than perform any other movement, by the 
circumstance of its occipital extremity receiving the 
largest share of the uterine force, in consequence of its 
being nearer and more in a line with the spine, through 
which, as we have seen, this force is transmitted, and 



272 SPECIAL PHENOMENA OF SECOND STAGE. 



under this impulse the occiput will move in whatever 
direction the least resistance is offered, which is toward 
the pubic arch, because here is at once the outlet of the 
pelvis and of the genital organs ; and while there is, of 
course, no resistance from the pelvis, there is but little 
from the soft parts. The attraction which the pubic 
arch may, therefore, be said to have for the occiput, as 
well as the repulsion of the forehead by the internal 
surface of the ossa pubis, causes anterior rotation to oc- 
cur more frequently than posterior, in the third and 
fourth positions of the vertex. But neither this attrac- 
tion nor repulsion is so strong as always to compel the 
occiput to move forward, in these positions ; if the hol- 
low of the sacrum offer unusual space, or the head be 
small, the occiput will be directed posteriorly. 

Diagnosis. 
It is generally easy to distinguish the vertex from 
any other part of the child that may present ; its regu- 
lar convexity, smoothness, and hardness, together with 
its commissures and fontanels, one of which at least 
can always be felt, when the os uteri is sufficiently 
opened, will scarce allow even the least experienced to 
mistake it. It may often be felt through the mem- 
branes, with a sufficient number of these characteristics, 
to enable us to pronounce positively as to its presence 
at the superior strait ; but if any obscurity exist then, 
all doubt may be removed after the membranes are rup- 
tured. It is not so easy a matter to make out the 
position of the vertex, though practice ought to enable 
any one, possessing ordinary tact, to do this with a great 
deal of accuracy. To determine this point, the finger 



I 



VERTEX PRESENTATION. 273 



must be introduced deeply and then directed upward, 
to feel for the sagittal commissure, which looks dov/n- 
ward and backward in the direction of the axis of the 
superior strait, at least in the early stage of labor ; the 
sagittal commissure being found near the center of the 
pelvis, the finger traces it anteriorly until the fontanel, 
which is opposite one of the acetabula, is found. To 
reach this, the finger must be passed, in the absence of 
pain, between the cervix uteri and head of the child, to 
a greater or less distance, according to the degree of 
dilatation of the os uteri and the greater or less flexion 
of the head. The finger having arrived at the fonta- 
nel, the examiner ascertains whether it is the posterior 
or anterior, which is determined by the number of con- 
current commissures belonging to it : if four commis- 
sures can be traced into it, and it be lozenge-shaped, it 
is the anterior fontanel; if, on the contrary, only three 
commissures run into it, and it be triangular, it is the 
posterior fontanel. Now, if the sagittal commissure 
crosses the pelvis, in the direction of its left obhque di- 
ameter, and the posterior fontanel is found opposite 
the left acetabulum, the vertex is placed in its first po- 
sition ; but if, the sagittal commissure crossing in the 
same direction, the anterior fontanel is opposite the 
left acetabulum, the vertex occupies its third position. 
If it be found that the sagittal commissure corresponds 
to the right oblique diameter of the pelvis, then it is 
the second or fourth position, according as it may be 
the posterior or anterior fontanel, which is discovered 
opposite the right acetabulum. 

Both Naegele and Higby speak of the equal facility 
of reaching the two fontanels, and declare that although 
18 



274 SPECIAL PHENOMENA OF SECOND STAGE. 



the posterior is most frequently lowest, occasionally the 
reverse is the case, and it is the anterior fontanel, with- 
out at all influencing the progress of the labor. 

This does not agree with my experience, and I must 
candidly avow that whether it has been owing to my 
awkwardness, or the limited reach of my finger, I have 
not been able to feel both fontanels, in a single instance ; 
and I can never feel the fontanel that is placed posteri- 
orly, except in the occipito-posterior positions, and then 
only after the head has flexed so considerably as to carry 
the anterior fontanel above the reach of the finger. 

Most British authors dkect us to feel for the ear of 
the child, that is immediately behind the pubes, in or- 
der to determine the position of the head. " When you 
are desirous of discovering the situation," says Dr. Blun- 
dell, " make it your first endeavor to distinguish the 
ear, by interposing the finger between the symphysis 
pubis and the head of the fetus ; and there, if the ac- 
coucheur he sJcillful, and the condition of the labor natural, 
even in the earlier parts of labor, the ear may be felt 
without difficulty. Again, anxious to ascertain the po- 
sition of the head, examine the ear once more, taking 
care not to double the part upon itself, observing care- 
fully which is the flap of the ear, and which is that part 
of the ear which is hound doivn close upon the head ; for 
the flap of the ear lies toward the occiput, as the part 
which is sessile is lying toward the face, so that where 
you feel the ear, and take care not to displace and falsify 
its indications by doubhng upon itself, observing re- 
spectively those parts which are attached and disen- 
gaged, you may make out the situation of the face and 



VERTEX PRESENTATION. 275 



k 



occiput with facility and precision " (1). I must confess 
that my endeavors to feel and distinguish the ear have 
been, so far, quite unavailing. As, however, to do this 
may not be so difficult as I imagine, it is proper that I 
should vindicate myself from the imputation of extraor- 
dinary obtuseness, by stating that I have made but few 
attempts to feel the ear, being accustomed to rely on the 
more precise information afforded by the commissures and 
fontanels, and even in those few instances, the usual po- 
sition, in which my examinations are made, viz., on the 
back, is not so favorable for auricular researches, as the 
universal obstetric position of British practitioners. 

If an examination be made, for the first time, after 
labor has been greatly protracted, and considerable intu- 
mescence of the scalp has taken place, or sometimes at 
an earher period of labor, where the ossification of the 
head is so advanced as to obscure the commissures and 
fontanels, it may not be possible to ascertain the exact 
position of the head. Here, auscultation may afford us 
some aid. If the pulsations of the fetal heart can be 
distinctly heard, we may be sure that the back of the 
fetus is turned toward the side of the mother where 
they are heard; and if, therefore, they are heard in the 
left-iliac region, we may be sure that it is a case of either 
the first or fourth position, most probably of the first, 
inasmuch as this is so much more common than the 
fourth. K, on the contrary, these pulsations be discov- 
ered in the right iliac region, it is conclusive evidence of 



(1) Lectures on tlie Principles and Practice of Midwifery, ed- 
ited by Charles Severns, M. D., Philadelphia edition, 184*2, p. 
108. 



576 SPECIAL PHENOMENA OF SECOND STAGE. 



either second or third position, most likely of second, as 
this occurs more frequently than third position. 

Prognosis. 
Vertex presentation is decidedly more favorable 
than any other for both mother and child, especially for 
the latter. The reason of its preferableness will be 
best apprehended, when the disadvantages of all other 
presentations are pointed out. But the several posi- 
tions of the vertex are not equally favorable, the third 
and fourth being less so than the first and second. The 
cause of difficulty and danger in the occipito-posterior 
positions was explained in connection with their mechan- 
ism ; we know now, however, that they are not so much 
to be dreaded as they formerly were, because they are 
apt to be spontaneously converted into occipito-anterior 
positions, and even where this fails to take place, the 
expulsion of the head is not necessarily very tedious 
and hazardous. On the contrary, I have witnessed cases 
of this kind, in which the labor was terminated with 
reasonable facility, and safely for mother and child. M. 
Capuron errs, therefore, in considering these positions 
so unnatural that they might be refused admission 
among the regular vertex positions, and so difficult, that 
they necessitate delivery by the forceps (1). While it 
should not be forgotten that they involve some risk, our 
confidence in the resources of nature (always propor- 
tioned to the care with which we have studied them), 
should restrain us from resorting hastily to instrumental 
or other extraordinary assistance. 

(1) Cours Theorique et Pratique d'Accouchemens, p. 200. 



VERTEX PRESENTATION— MANUAL AID. 277 



CHAPTER XV. 

Manual assistaiice ivhen the head or shoulders are 2^asS' 
ing — or tvhen, the head being horn, the cord is coiled 
round the neck — the expidsion of the head retarded 
hy its occipito-posterior position^ or by contrac- 
tion of the cervico'iderine orifice aboid the neck of the 
child. 

It was formerly the established practice of accou- 
cheurs, in vertex cases, to lay hold of the head as soon 
as it is \vithin reach of the hands, and extract the 
shoulders without delay, lest the child should be suffo- 
cated by its detention in the passage. Mauriceau, for 
example, directs that when the head is expelled as far 
as the ears or thereabouts, the midwife is to seize it 
with both hands, apphed upon the sides of the head, 
some of the fingers being insinuated under the jaw, and 
then the occasion, offered by the first good pain, must 
be embraced to bring forth the child, by drawing its 
head (1). He gives particular directions as to the man- 
ner of exerting this extractive force, which must not be 
always in a right line, but often fi:om side to side, in 
regard to the head, in order that the shoulders may 
sooner and more easily take its place, after it has pas- 
sed, and be made to follow without delay. 

Baudelocque does not consider it more expedient to 

(1) Livre 11, chap. 7. 



278 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



take hold of the head with the hands than to pull it 
forth by the ears, which the vulgar imagine the accou- 
cheur is always careful to do; but he allows that when 
the head is almost born, it should be assisted by raising 
it toward the pubes or insinuating the index finger un- 
der one side of the lower jaw ; and directs that after its 
disengagement, the face should be turned toward one of 
the thighs of the mother, that toward which it tends. 
We are next, according to this celebrated author, to in- 
quire into the situation of the shoulders, or relatively 
to the inferior strait ; push one of them toward the sa- 
crum, and bring the other under the pubes, when they 
are not naturally thus placed, and then extract . them, 
together with the rest of the trunk, by cautiously pul- 
ling upon the head (1). M. Baudelocque is careful to 
forbid, as unsafe, the apphcation of great force in this 
manner, when the size of the shoulders offers any con- 
siderable obstacle ; but advises instead that the index 
of each hand be introduced under the axillse, and used 
as crochets. We must not forget, he emphatically adds, 
to place the shoulders in the situation already indicated, 
before we attempt to extract them, for those of the 
smallest dimensions cannot pass out transversely, without 
extreme difficulty. 

The manipulation recommended by Mauriceau, which 
appears at one time to have been generally practiced, 
was, doubtless, part and parcel of the pragmatic mid- 
wifery in vogue, and must be presumed to have been often 
pernicious in its results. To the writings of Mr. Charles 

(1) L'Art des Accouchemens, par. 825-7. 



MANUAL AID. 279 



White, of Mancliester, England (1), we are largely in- 
debted for such an exposure of its absurdity and danger, 
as has consigned it to merited reprobation. In the chap- 
ter of his popular work, on " Natural Bkths, particularly 
of the Secundines, and the prevention of afterpains," 
he shows the folly and risk of such practice, by contrast- 
ing it with the operations of nature, when she is per- 
mitted to pursue her own course unmolested. Accord- 
ing to nature's process, the shoulders are caused to make 
such turns as best adapt them to the dimensions of the 
pehis and soft parts ; whereas, when art interposes, in 
the manner deprecated, the shoulders are pulled along 
transversely, offering violence to the vagina, and unduly 
distending the womb and its ligaments, thus producing, 
as Mr. White had reason to beheve, " inflammations, 
prolapsuses, retentions of urine, and a train of disagree- 
able symptoms." " This improper and too hasty deliv- 
ery of the shoulders, in natural labors, occasions," he 
adds, "the retention of the secundines, and is in some 
manner the cause of afterpains; for the womb being im- 
properly stretched out, and the body of the child pre- 
maturely dehvered without a natural pain, the womb, 
instead of contracting regularly fi'om its fandus, is 
thrown into spasmodic strictures, either at its mouth or 
across its middle." There is no difficulty in perceiving 
how such an uTegular contraction of the uterus, or, wdiat 
is, perhaps, fully as often the case, atony or a flaccid 
condition of the organ, the consequence of its being too 
suddenly emptied, may be foUowed by retention of the 



(1) Treatise on tlie Management of Pregnant and Lying-in 
Women,, second edit., London, 1777. 



280 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



placenta, and likewise flooding, if it be wholly or par- 
tially detached from the uterus. Of the fact that such 
a procedure is hkely to be follow^ed by unusually severe 
afterpains, there can be no reasonable doubt ; but Mr. 
White's explanation of the manner in which these 
are caused cannot be readily admitted. He ascribes 
them to the closure of the mouths of the uterine 
sinuses or veins, before they could have an opportunity 
of gradually contracting and of discharging themselves 
of the blood which they contained, " the serous parts of 
which drains away and leaves the crassamentum behind 
in the sinuses, which grows the more fibrous the longer 
it remains ; and the parts being irritated by this extra- 
neous body, endeavor to disburthen themselves, by what 
are called afterpains." We rather judge that these after- 
pains result from contractions of the uterus, provoked 
by the presence of large coagula in its cavity, the pro- 
duct of internal hemorrhage, permitted by the flaccid or 
irregular contracted state of its parietes, foUowing such 
hasty deUvery. 

The foregoing considerations ought to suflice to set- 
tle the conduct of the practitioner, in ordinary cases of 
labor with vertex presentation ; it should be a maxim 
with him, that nature must be allowed to do her work, 
in her own good way, seeing everything has been ordered 
with admirable foresight, to have it accomplished with 
the greatest safety and the least suffering to mother and 
child. It does, nevertheless, not unfrequently happen 
that some assistance may be usefully given, with a view 
to promote the passage of both the head and shoulders, 
in vertex cases: and to deny this, and dogmatically to 
affirm the universal sufficiency of nature, is to humiliate 



MANUAL AID. 281 



art without exalting nature, unless it be vainly imagined 
that she is exalted by the incense of bhnd adoration. 

Let us inquke, then, what may be safely done to 
favor the release of the head, when it is pressing on the 
perineum, but its exit is unduly delayed. The delay 
may arise from the resistance of the soft parts at the 
outlet, or from the inadequacy of the parturient powers 
to cause the head to execute the movement, by virtue of 
which it cleai's the vulva. The execution of this move- 
ment (extension), it has been shown, requires a degree 
of uterine force, of which they alone have any just concep- 
tion, who have carefully studied the mechanism of labor. 
In either case, firm and properly directed pressure on the 
perineum will avail much in promoting the birth of the 
head, by aiding the movement in question. The pres- 
sure should be, of course, from the extremity of the 
sacrum toward the symphysis pubis, and so managed as 
not only to push the forehead of the child in that direc- 
tion, during a pain, but as much as possible in the inter- 
vals of the pains, so as to retain whatever advantage is 
gained. The patient l}ing on the back, both hands, 
with the extremities of the fingers dkected toward the 
sacrum, may be employed in raising the head, as it were, 
toward the pubes. By acting thus, I have often suc- 
ceeded in having the head expelled by a few pains, 
notwithstanding it had made no advance for hours pre- 
viously, and there appeared to be no prospect of its 
expulsion by the unaided efforts of nature. Of Baude- 
locque's maneuver, slipping a finger or two under the 
jaw, much less of Mauriceau's, laying hold of the head, 
for the purpose of making traction upon it, I have no 
experience. 



282 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



In relation to the passage of the shoulders, it must 
be remembered that a short respite usually ensues after 
the expulsion of the head, in the most natural cases — 
during which the tonic contraction is at work, reducing 
the uterus to the diminished volume of its contents. 
We should, therefore, be satisfied to support the head, 
and wait awhile for the resumption of expulsive efforts. 
If this respite should, however, be protracted, or if the 
child be in a suffering condition, from pressure upon its 
neck interrupting the return of blood from the brain, 
and producing engorgement and lividity of its face, the 
interposition of art is not only proper but imperiously 
demanded. Under such circumstances, the practitioner 
should get two fingers (one is hardly sufficient) under 
the axilla, and use such extractive force as may be ne- 
cessary to advance the shoulders. If the shoulders be 
found situated nearly transversely in the pelvis, one ax- 
illa (that which is most forward, if they be not directly 
transverse, either if they be transverse) is to be drawn 
toward the pubes, and then they are to be brought 
through the vulva, in a manner as exactly imitative of 
the mechanism as possible. In rendering this assist- 
ance, it is important to observe that it must be confor- 
mable to nature in other respects beside her mechanism; 
this might be exactly copied, and yet the woman be 
left in a most perilous condition. Our extractive force 
must be cautiously applied, and alternated with inter- 
vals of rest, and we must be careful to have the coope- 
ration of the natural efforts, or at least be sure that the 
uterus is in a contracted state. To pull away the child, 
while the uterus is altogether passive, would be hazard- 
ous in the extreme ; but no such hazard is incurred by 



UMBILICAL CORD AROUND THE NECK. 283 



a prudent and well-instructed practitioner, for it almost 
uniformly happens that his efforts are seconded by those 
of nature — the introduction of his fingers and the dis- 
placement of the shoulders, serving to excite a renewal 
of the suspended contractions of the uterus. Of pull- 
ing on the head, as a means of acting upon the shoul- 
ders, I have no experience ; but it seems to me that it 
is not free from danger, as far as the child is concerned, 
while it cannot enable us to conform the transition of 
the shoulders so accurately to the mechanism, as the 
method I have advised and often practiced. 

After the birth of the head, it is not at all uncom- 
mon to find the umbilical cord coiled once or more 
around the neck of the child. My attention has been 
particularly dkected to this among other points, and I 
find that the cord is around the neck in a much larger 
number of vertex cases, than I hadpreviously supposed, 
or than is suspected by those who have made no particu- 
lar inquiry concerning it. 

It was, at one time, very generally believed that 
such a disposition of the cord may operate as a serious 
impediment to the expulsion of the head, — the short- 
ened cord retracting the head upon the subsidence of 
each pain, — and it was even deemed necessary, in some 
instances, to divide it with the scissors to allow the 
head to emerge. Dr. Smellie, who recognized this as 
an obstacle to dehvery, advises a different method of 
overcoming it. In one of his numbers (1), quaintly en- 
titled, " How to behave when the birth is obstructed by 
the navelstring, etc.," he recommends one or two fin- 

(1) V of Section III, Chapter II, Book III. 



284 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



gers to be introduced into the rectum, before the pain 
goes oiF, to press upon the forehead of the child at the 
root of the nose, taking care to avoid the eyes : " this 
pressure," says he, " detains the head until the return 
of another pain, which ^Yill squeeze it farther down, 
while the fingers, pushing slowly and gradually, turn 
the forehead half round outward and half round upward. 
By this assistance and the help of strong pains, the 
child will be forced along, although the neck be entan- 
gled in the navelstring; for, as the child advances, the 
uterus contracts, and consequently the placenta is moved 
lower: the funis umbilicalis will also stretch a little, 
without obstructing circulation." Although Dr. Smel- 
lie recites some cases, in one of his Collections, in 
which labor was apparently obstructed by this cause, 
there is reason to doubt its reality, nor can any assist- 
ance that may have been rendered by his anal manipu- 
lation be adduced in its support, for the efficacy of pres- 
sure, as practiced by him, may be explained upon a 
quite different principle. The alternate advance and 
recession of the head may, much more reasonably, be 
attributed to the resistance of the perineum, aided per- 
haps by the elasticity of the fetal cranium ; and this re- 
sistance may be overcome, in a shorter time, by the 
head being made to press uninterruptedly upon the 
soft parts at the pelvic outlet. 

When the head is expelled, there is still reason to 
doubt whether the cord, by encircling the neck, can hin- 
der the expulsion of the remainder of the child ; but, 
under such circumstances, both mother and child are 
undoubtedly exposed to serious accidents. The cord 
may be lacerated, the placenta may be torn loose from 



UMBILICAL CORD AROUND THE NECK. 285 



the uterus, or if its attachment be strong enough, the 
uterus may be inverted, and, finally, the child may be 
lost by the ligature of its neck intercepting the return 
of blood from its brain. I have not met with any in- 
stances of flooding or inversion of the uterus from this 
cause, but I have known the cord to be lacerated and 
the child's face to be swollen and livid. It should, 
therefore, be an invariable rule of practice, in vertex 
cases, to ascertain, as soon as the head is born, whether 
the cord is around the neck or not: if it be found there, 
it should be gently pulled and slipped over the head, if 
a coil of it can be sufficiently loosened to allow this ; 
but if this cannot be done, without too great stretching, 
it may be pushed over the shoulders, as they emerge 
from the pelvis. Where several circles of the cord sur- 
round the neck so tightly as to choke the child, it will 
be proper to divide it at once with the scissors, and 
hasten the birth, as much as is compatible with the 
safety of the mother, lest it be lost from hemorrhage or 
asphyxia. 

Labor may be protracted, in vertex cases, in conse- 
quence of the occiput being turned toward the posterior 
part of the pelvis, especially if the occiput should rotate 
into the hollow of the sacrum ; and it has, therefore, 
been deemed an important practical precept to secure 
the turning of this part of the head toward the pubic 
arch. For this purpose, we are duected to press upon 
the coronal region of the head, near the anterior fonta- 
nel, with two fingers, and push it toward the sacrum, to 
convert a third into a second, and a fourth into a first, 
position of the vertex. From the observations already 
made in the preceding chapter, it may be gathered that 



286 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



I do not highly appreciate this manipulation. If, how- 
ever, it should happen that no tendency to this desira- 
ble mutation is manifest, although the time when it 
usually occurs has arrived, it is the duty of the practi- 
tioner to interpose and do what he can to have it ac- 
complished. He ought not, and, if he is wise, will not, 
pretend to more vigilance than nature, and make pre- 
mature efforts to direct her movements. 

A far more serious cause of protracted labor, pecu- 
liar to vertex presentations, consists in the permanent 
contraction of the cervix uteri about the neck of the 
child. This was formerly described by authors as con- 
traction of the OS uteri upon the child's neck, after the 
head had passed through it and is lodged in the vagina; 
but Baudelocque was doubtless correct in assigning the 
upper extremity of the uterine neck ( the cervico-ute- 
rine orifice) as the seat of this permanent contraction. 
Numerous observations have proved the remarkable 
proneness of this part of the uterus to contraction, 
whenever the cause that distends it is removed. Thus, 
it is truly remarked by Madame Lachapelle that, for a 
certain time after natural delivery, the external orifice, 
as well as the entire neck, is found soft, lax, and open, 
while the internal orifice is small and contracted; and, 
in speaking of the difficulties that may be encountered 
in the operation of version, she says that she has often 
met with contraction here, consequent upon the escape 
of the waters, as the only obstacle to the introduction 
of the hand (1). 

(1) Pratique des Accouchcmens, Deuxieme M^moire. 



CONTRACTION OF THE CERVIX UTERI. 287 



This condition of the cervico-uterine orifice oiSers an 
impediment to the advance of the shoulders of the child, 
and, of course, the head is retained in the cavity of the 
pehds, and cannot be expelled or extracted until the im- 
pediment is removed. It is characterized })y the head 
making no progress, although the pains be strong and 
regular, the os uteri dilated, and the pelvis amply capa- 
cious, or if the head be forced lower during a pain, it is 
retracted as soon as the pain dechnes. It cannot, how- 
ever, be certainly discovered except by a tactual exam- 
ination, in order to which the head must first be raised, 
by the entire hand, above the brim of the pelvis -, and 
then the fingers may be pushed up between the os uteri 
and head, at the base of which the stricture wiU be de- 
tected, if it exist. 

Premature rupture of the membranes may be reck- 
oned the most common, if not the sole, cause of the ab- 
normal contraction we are considering. When this un- 
toward event occurs, the liquor amnii is hable to flow or 
dribble away before the head can stop the os uteri by 
engaging in it. The uterus being thus deprived of its 
waters, the tonic contraction brings its parietes every- 
where into contact with the surface of the child's body, 
but more especially and with greater rigidity, at the 
cervico-uterine orifice, for the reason already stated. To 
this cause alone it is attributed by Smelhe; and in all 
the instances described by him, it is particularly men- 
tioned that the membranes had long been ruptured, the 
waters drained ofi", and the labor lingering. 

The treatment consists in the dilatation of the con- 
tracted portion of the uterus by the fingers, insinuated 



288 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



between it and the neck of the child. This can be ac- 
compHshed only by first elevating the head above the 
superior strait, for there is not room in the excavation 
to receive the hand between it and the pelvic walls. 
When, therefore, the diagnosis is estabhshed, in the 
manner already explained, we should proceed at once, 
without withdrawing the hand, to remedy the difficulty. 
The stricture being dilated, the hand should be suddenly 
withdrawn, upon the access of a pain, that the shoulders 
may take its place, and prevent a recurrence of the 
accident. 

Should labor be long delayed by this obstacle, it is 
evident that the parturient powers may become so ex- 
hausted, that the case may be mistaken for one of sim- 
ple impotent action of the uterus, and, under this im- 
pression, a practitioner might attempt to deliver with 
the forceps. Smellie records a very interesting case of 
this kind, in which the woman had been five days in 
labor, and had been neglected by the surgeon and mid- 
wife. She had lost a great deal of blood, was very 
weak, and the head of the child was low down in the 
pelvis. Smellie tried to deliver with the forceps, but 
was surprised that he did not succeed, because the head 
was not large, and the instrument was easily introduced, 
and firmly fixed. Being foiled in this method, he open- 
ed the head, and tried to extract it with the blunt hook 
on the inside of the skull, assisted by his fingers ; but 
could not, with all his strength, bring it along. "How- 
ever," says he, "by extracting the occipital and one 
of the parietal bonCvS, I had room to introduce my 
hand, so as to find with my fingers the under part of 



CONTRACTION OF THE CERVIX UTERI. 289 



the uterus strongly girt or contracted round the neck 
of the fetus ; this I gradually dilated ; then bringing 
down one of the arms, and pulling at that, and the 
shattered bones and scalp, with both my hands, I at 
last extracted the child with greater ease than I 
expected" (1). 



(1) Collection XXXI, Case YI. 



19 



290 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



CHAPTEE XVI. 

INSTRUMENTAL DELIVERY IN VERTEX PRESEN- 
TATION. 

The parturient powers may-j as we have seen, prove 
insufficient for the expulsion of the child, in such time 
as best comports with its and the mother's safety, and 
it then becomes necessary to resort to various instru- 
ments that have been devised by art to terminate the 
labor. The use of instruments may, also, be demanded 
on account of accidents, such as convulsions, or flooding, 
occurring in the progress of labor. Instrumental deliv- 
ery, in vertex presentations, shall therefore next claim 
our consideration; and in discussing this subject I pur- 
pose to limit my remarks to the use of the common 
forceps and crotchety the only instruments much em- 
ployed in the practice of this country. 

First. Delivery ly the forceps. 
The forceps is an instrument consisting of two 
branches, which are separately introduced within the 
organs of the mother, and then joined together, to em- 
brace the child's head and extract it. Its use is com- 
patible with, and is, indeed, designed to save, the life of 
the child, w^hile the mother is secured against the danger 
of longer continuance of her travail, A short descrip- 
tion of it is necessary to enable the reader to compre- 



THE FORCEPS. 291 



hend the dkections which are to be given for its 
employment. 

The branches of the forceps I shall, after M. Duges, 
designate riglit and left, because the former is held in 
the right hand, when it is being introduced, passes up 
on the right side of the pelvis, and in the great majority^ 
of cases (viz. in the occipito-anterior positions), is ap- 
plied upon the right side of the head, and vice versa 
with regard to the former. We distinguish, as belonging 
to each branch, a blade, handle, and intermediate part, 
which serves to lock them, when they are properly 
brought into apposition. The blade {cidller of the 
French) is broad, concave on one side, convex on the 
other, and fenestrated in its whole length : the handle 
is round, straight, or slightly curved, and of various 
lengths in different forceps: the lock is formed by a 
conical pivot or screw on one branch, and a mortice or 
notched hole in the other to receive the pivot. The 
pivot belongs to the left branch, and the mortice or hole 
to the riglit^ and these articular contrivances have given 
names to the branches themselves, — the left being 
called the male^ and the right, the female^ branch, by 
Baudelocque, Dewees, and many others. 

No instrument of surgery or obstetrics has under- 
gone so many metamorphoses as the forceps, since its 
first rude conception — almost every distinguished opera- 
tor having proposed some change of its shape or dimen- 
sions. I shall not discuss the merits, real or imaginary, 
of the different kinds of forceps that have been hence 
produced ; but shall content myself with avowing my 
predilection for that of the French, admitting, at the 
same time, that a skillful operator may succeed very 



292 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



well with any of the instruments in use, and will suc- 
ceed best with the one he is accustomed to handle. It 
is proper, I should say, that the forceps I use is the 
French, curtailed by reducing the length of the handle 
and lock, which is not essential except for dehvering 
from above the superior strait, — an operation seldom 
performed in this country, and which, I am persuaded, 
is too frequently performed on the other side of the 
Atlantic. The blades of my forceps correspond in shape, 
breadth, and length with the French, but when joined, 
they are rather wider apart, as they are not designed 
to go beyond a contracted or deformed superior strait, 
and it is necessary that the space between them should 
nearly include the head, else the (straight) handles 
would be inconveniently separated, when the head is 
embraced. It is only necessary to add that the blades 
of my forceps have, of course, a curvature upon their 
edges, adapting them to that of the pelvic canal, as 
well as the curvature upon their faces, common to all for- 
ceps, adapting them to the convexity of the head (1). 

In treating of forceps operations, the method which 
I shall pursue will be, first, to make some general ob- 
servations on this mode of delivery, and then describe 
the operative procedure, appropriate to the different sit- 
uations of the head. 

General ohservations. — ^AVhen it is judged expedient 
to deliver with the forceps, suitable preparation must be 

(1) The Forceps used by me was made, according to my direc- 
tion, by Mr. Erringer, of this city, Surgical Instrument maker. 
Third street, who has the pattern of it, and keeps it, in fact, con- 
stantly on hand. From him it can be had by any who may desire 
to possess it. 



THE FORCEPS. 293 



made for the operation. A mattress must be provided 
for the patient to lie on, as the sinking of her hips in a 
feather bed would be inconvenient, and she must be 
placed in a proper position, with the pelvis near the 
side or foot of the bedstead. As to the "proper posi- 
tion," there is a diversity of opinion and practice — the 
French directing the patient to be placed on the back, 
while the English strenuously insist on the prefera- 
bleness of their universal "obstetrical position," viz., on 
the left side. For my own part, I have never attempted 
to deliver with the forceps, the patient lying on her 
side- but, it seems to me, that the dorsal position is far 
more convenient, and permits the operator to recognize 
more accurately the relations of the head to the cardi- 
nal points of the pelvis. Baudelocque, Dewees, and 
others, dkect that the hips should be so near the edge 
of the bed, that the perineum may be free, the feet be- 
ing supported on stools, or the laps of assistants : but 
this is not necessary, unless where the head is high up, 
or not at all engaged in the pelvis. It will be sufficient, 
if her hips are placed so near the side of the bed that, her 
lower extremities being strongly flexed, her feet rest on 
its verge, and, if necessary, her pelvis can be raised by 
a cushion or a folded quilt. If there is any distention 
of the bladder, the urine must be drawn off with the 
catheter; and if the bowels are loaded, they must be 
reheved by a purgative injection. 

The operation may be divided into two parts ; first, 
the introduction and adjustment of the branches of the 
instrument, and second, traction with it, when properly 
adjusted, to extract the head. In the first part of the 
operation, the object to be attained is to apply the 



294 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



blades of the forceps upon the sides of the head oppo- 
site to each other, being careful to have their concave 
edges turned either directly or obliquely forward, as 
regards the mother, according to the situation of the 
head. The left branch is, as a general rule, to be intro- 
duced first; the practitioner takes this in his left hand, 
and holding it near the lock, between his thumb and 
fingers, as a pen is held, in writing, he presents the ex- 
tremity of the blade to the vulva, his hand being per- 
pendicularly over the right groin of the patient. As this 
branch passes up along the left side of the pelvis, the 
hand is moved toward the left side until it reaches mid- 
way between the thighs of the patient, while at the 
same time, it is depressed in a very decided manner 
The first movement is in accommodation to the curva- 
ture upon the face of the blade, whose extremity glides 
from left to right over the convexity of the head : the 
second is to accommodate the curvature of its edge, 
which must correspond with the curved axis of the pel- 
vic canal. Two fingers, or preferably, when practicable, 
all the fingers of the right hand, previously well-lubri- 
cated, are to be introduced as high up as possible, be- 
tween the head and pelvis, to serve as a conductor of the 
blade, to prevent its contusing the vagina, and to insure 
its passage into the cavity of the uterus. 

Should any difficulty be experienced in the intro- 
duction of the blade, it is to be surmounted by address, 
never by force; if the vulva be rather contracted, dilate 
it with the fingers; if the progress of the blade be ar- 
rested, vary the direction of its extremity, and advance 
it gently with a vacillatory motion. When its introduc- 
tion is satisfactorily accomphshed, it should be given in 



THE FORCEPS. 295 



charge to an assistant, instructed to resist any displace- 
mentj which the uterine contractions may tend to pro- 
duce. 

The practitioner then takes the right branch in his 
right hand, and introduces it in the same manner, mutatis 
■mutandis^ as the left. That it may lock with its fellow, 
it is requisite that it be placed precisely in opposition 
to it. Should this be found to be not the fact, it must 
not be forcibly twisted into its proper place, for such an 
attempt might inflict serious violence on the child's head, 
and also upon the uterus ; but it should be partially or 
wholly withdrawn, and another du'ection given to it. 
Proceeding after this manner, repeatedly varying its line 
of march, if need be, we shall at length safely obtain 
the desired position, and have no difficulty in locking 
the instrument. 

The instrument, being properly applied, is to be ta- 
ken hold of with both hands, one at the lock, and the 
other near the extremity of the handle, the forefinger of 
the former being at hberty to examine, from time to 
time, the progress we are maldng. The handles are to 
be pressed together with sufficient firmness to clasp the 
head and prevent the slipping of the blades, when ex- 
tractive force is used, but not so powerfully as to com- 
press the head, much less to contuse it or fi^acture its 
bones. On this point, a young practitioner needs to be 
cautioned, and he should keep a constant watch upon him- 
self, as he will be very apt to use com^jressin^, propor- 
tioned to the extj' active^ force he finds it necessar}^ to 
exert. The extraction now commences, and this is to 
be performed, fi:om first to last, in conformity at once 



296 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



mth the nature of the instrument and that of the pro- 
cess it is intended to expedite. 

On the first topic, it must be considered that the 
forceps is not merely a tractor, but it is also a lever, — 
a double lever of the first kind — the prop being at its 
pivot, the resistance, viz., the head, at the blades, and 
the power at the handles. It is as a lever, more than a 
tractor, that we use the forceps ; consequently, while we 
draw toward us, or in the direction of the axes of the 
pelvis, with moderate force, we move it from side to side, 
or, as the phrase is, from handle to handle. The head 
is, therefore, brought along, by describing a succession 
of slight curves, in alternately opposite directions, of 
which the pivot is the center, and no more traction is 
employed than is necessary to preserve the advantage 
gained by the lever. In moving the instrument to and 
fro, the operator should be careful not to exceed the lim- 
its to wdiich he may safely venture, for it is evident that 
a reckless swinging of it will necessarily contuse the 
organs of his patient, and may be followed by the most 
deplorable consequences. It is, however, proper to ob- 
serve, for the encouragement of the prudent, that no 
danger need be apprehended from this source, except 
from inexcusable negligence or temerity. 

The duty of imitating the process of labor suggests, 
in the first place, that our extractive efforts should be 
made with intervals of rest. The artificial force ought 
not to be of longer duration than the natural, nor its 
respite shorter ; it ought not to be put forth, in all its 
intensity, in the beginning, but be gradually augmented 
to the required degree; and we should act in concert 
with the pains, if they continue to recur with their 



THE FORCEPS. 297 



wonted freqnencyj thougli AYitli inadequate force. It 
suggests, in the second place^ that Ave follow the me- 
chanism of labor, by causing or assisting the head to per- 
form whatever movements remain to be executed, in 
order that it may emerge easily and safely from the pel- 
vis. When, finally, the head is made to distend the 
perineum, our extractive efforts must be greatly mitiga- 
ted, if not altogether intermitted, lest the perineum be 
torn by its too hasty delivery. The handles of the for- 
ceps are now to be held by one hand, which is more 
than enough to exert all the force that can be needed, 
while the other hand is employed in supporting the per- 
ineum, as in natural delivery. By some authors we are 
dkected to take off the instrument, at this stage of the 
operation, as the stronger pains and more powerful ef- 
forts of the patient, which usually occur, are sufficient 
to insure the expulsion of the head ; but my own prac- 
tice is to leave it on, as its presence can do no harm, 
and it might be wanting: I have, indeed, usually con- 
tinued to make shght tractions with one hand, while, 
with the other, the perineum is supported until the 
head is born. 

When the head is extracted, the rest of the child 
may be expelled by the contractions of the uterus; but 
it is not unfrequently the case, especially where labor 
has been much protracted, that it is necessary to assist 
in the manner explained in the last chapter. 

These general observations being premised, we have 
now to consider the special application of the forceps, or 
the method of proceeding in the several positions in 
which the head may ofier, — it being understood to be 



298 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



engaged in the pelvis, for, of the use of the forceps when 
the head is at the brim, I do not propose to treat. 

Dr. Dewees enumerates as many as eight different 
positions of the head, requiring different procedures on 
the part of the operator; but I do not perceive the util- 
ity of such multiplication, which appears to me calcula- 
ted to embarrass rather than assist us at the bedside. 
An acuteness of tact, enjoyed by but few, is necessary 
to the recognition of these various positions; and in a 
considerable number of cases, no acuteness will enable a 
practitioner to detect them with certainty. Such will, 
not unfrequently, be his inabihty if he is called in late, 
and solely on account of the difficulty of the labor, 
when the swelling of the head and the approximation of 
its bones may have obliterated the marks, which usually 
serve to indicate its position. It would, then, be fortu- 
nate for him, if it v/ere only needful to pay attention to 
as many of these positions as he can satisfactorily dis- 
criminate, and this, I believe, is the fact with regard to 
them. There are but three positions, or, as I shall de- 
signate them, situations^ of the head, which need be dis- 
criminated in reference to forceps operations. These 
are, 1. When the length of the head corresponds to the 
antero-posterior diameter of the inferior strait ; 2. When 
the length of the head corresponds to the left oblique 
diameter of this strait ; 3. When the length of the 
head corresponds to the right oblique diameter of the 
strait. By the length of the head is not, of course, 
meant its greatest occipito-frontal dimension (for it is 
in a state of greater or less flexion), but only its 
length in distinction from its breadth across the parietal 
bones. 



THE FORCEPS. 299 



It will be perceived, on a moment's reflection, that 
the second situation includes the first and third loosi- 
tions of the vertex, and the third situation includes the 
second and fourth positions of the vertex, while the 
first situation is only the product of the several vertex 
positions, after rotation has taken place. These situa- 
tions of the head may, it has been already intimated, 
be discriminated in practice, under any circumstances, 
whether the commissures and fontanels can be felt or 
not. The diagnosis is made out by attending to the 
completeness or incompleteness of the occupancy of the 
different points of the pelvis. The pelvis will be found 
most completely filled, in whatever dkection the length 
of the head may be placed, while a marked vacuity mil 
be observed in the direction of its breadth. Nor is this 
anything more than the mechanism of labor might, a 
lyriorij have led us to expect. In the direction of the 
length of the head, the pelvis is plenarily occupied, be- 
cause no greater flexion of the head takes place than is 
exacted as the condition of its entrance and descent, 
while the breadth of the head is rarely, if ever, so great 
as the dimensions of the pelvis. To distinguish the 
situation of the head, we have, therefore, only to push 
up a finger, or, if necessary, all the fingers, behind first 
one acetabulum and then the other; a plenum opposite 
to the left acetabulum and a vacuum opposite to the 
right discloses the second situation of the head, and vice 
versa in regard to the third; while the first situation is 
characterized by vacuities on both sides of the pelvis, 
and fiill occupancy of the concavity of the sacrum. 



300 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



I. ApiMcation of the forceps in the first situation 
of the head, or ivhere its length corresponds to the antero- 
posterior diameter of the inferior strait. 

In this situation of the head, the forceps is more 
easily applied than in either of the others, and less is 
to be done by its instrumentality. It only remains that 
the head execute its extension movement, that it may 
be released from its confinement. But it does not fol- 
low, that, because apparently but little is wanting, the 
forceps will be seldom needed. On the contrary, my 
own experience has satisfied me that the forceps will be 
as often rec[uired in this, as in any other situation ; nor 
should we be surprised at the necessity of it, w^hen we 
remember the disadvantageous lever represented by the 
head. 

Everything being prepared for the operation, as al- 
ready directed, the left branch of the forceps is to be 
taken in the left hand and introduced along the left 
side of the pelvis, conducted by several fingers of the 
right hand, until the handle is brought parallel with the 
axis of the vagina. This is to be held by an assistant, 
while the right hand introduces the right branch along 
the right side of the pelvis, under the conduct of the 
fingers of the left hand. When the handle of this 
branch is brought nearly parallel with that of the first, 
its notched hole easily receives the pivot, and the 
branches are locked, without difficulty. It will now be 
observed that the handle of the instrument is more or 
less elevated above the horizontal plane on which the 
patient lies, and the pivot is vertical. 

The left hand takes hold near the lock, and the 
right near the extremity of the handle, and the operator 



THE FORCEPS. 301 



proceeds to extract, in the manner already described, 
and in the du'ection of the axis of the inferior strait. 
As he progresses, it will be observed that the head ad- 
vances differently according as the occiput is toward the 
pubes or the hollow of the sacrum. In the first case, 
the occiput will easily emerge from under the symphysis, 
and rise toward the mons veneris, to make room for the 
forehead and face to pass out over the perineum. In 
the second case, the occiput moves over the inferior part 
of the sacrum and the coccyx, and comes out before the 
anterior edge of the perineum, when it falls backward 
to allow the forehead and face to pass out under the 
pubes. 

This observation will teach him, if he did not know 
it before, whether the occiput or the forehead is toward 
the pubes ; and the manner of using the forceps, as the 
head is dehvered, will be varied accordingly. If the 
occiput be toward the pubes, the handles of the instru- 
ment must, as the extraction proceeds, be raised toward 
a perpendicular, until at last they are even inclined to- 
ward the patient's abdomen, when the head is clearing 
the vulva. If the forehead be toward the pubes, the 
handles are raised, as the occiput is brought out before 
the perineum, and they are depressed as the head is 
clearing the vulva. The movement of the head, in 
both instances, strongly tends to impart such directions 
to the handles of the forceps, but it is right, not only to 
obey this tendency, but to increase it, or, in other words, 
to make tractions in conformity to it. 



302 SPECIAL TREATMENT OF VERTEX PRESENTATIOM. 



2. Ap2:)lication of the forceps in the second situation of 

the head, or luhere its length corresponds to the left 

oblique diameter of the inferior strait. 

The head being placed obKquely in the pelvis, in 
this situation it is evident that its sides cannot be em- 
braced by passing the blades of the forceps directly 
along the sides of the pelvis. They are, therefore, to 
be passed as follows: the left branch is held by the left 
hand, with its handle more elevated than in the first 
situation, and not quite so much inclined toward the 
right groin ; the fingers of the right hand, introduced 
along the left sacro-ischiatic ligaments, conduct its 
blades, which, as it ascends, is to be dkected across the 
sacrum. To do this, the handle must be lowered in a 
greater degree than in the first situation, while, at the 
same time, it is inclined toward the left thigh, toward 
which the pivot also inclines, instead of being vertical. 
The right branch is introduced under the right ramus 
of the pubes, and passes behind the right acetabulum, 
its handle and articular hole inclining toward the left 
thigh, in conformity with the corresponding parts of the 
left branch, when the pivot is readily received and the 
instrument is then locked. This coaptation is not, how- 
ever, always easily affected. It may happen that the 
second blade is not inserted exactly opposite to \ki^ first, 
and then, their articular parts not having the same in- 
clination, will not lock. In that case, the direction of 
the second blade, and sometimes of both, must be varied 
until they are made to join without force. 

The instrument is now to be firmly grasped with 
both hands, in the manner directed for the first situa- 



THE FORCEPS. 303 



tion, for the purpose of raising the handles and at the 
same time turning them over toward the symphysis 
pubis, until the pivot is made to assume a vertical direc- 
tion. The object of this maneuver is, to rotate the 
head preparatory to its extraction. It is usually accom- 
plished with facility, and then either the occiput or the 
forehead is brought under the symphysis pubes, accord- 
ing as it was a first or third vertex position. The rota- 
tion being accomphshed, the head is to be extracted as 
already explained under the first situation. 

3. AjjpUccdion of the foixeps in the third situation of 

the head, or zuhere its length corresponds to the right 

oUique diameter of the inferior strait. 

The same necessity of introducing the blades of the 
forceps obliquely, instead of directly on the sides of the 
peMs, exists in this as in the second situation. The 
left branch is introduced under the left ramus of the pu- 
bes, its blade is conducted behind the left acetabulum, 
and as it ghdes over the head in that direction, the han- 
dle, which was held high at first, is lowered so as to in- 
chne toward the right thigh, its pivot having also the 
same inclination. The right branch is then introduced 
before the right sacro-ischiatic ligament of the pelvis, 
and crosses the sacrum, its handle being depressed and 
carried toward the right side, as it enters, until it is 
brought to lock with the other branch. 

To articulate the branches is not quite so easy in this 
as in the second situation, for the right branch is under 
the left, and must be placed above it, before the hole can 
receive the pivot. A little management will, however, 
obviate this slight difficulty. 



304 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



The branches being joined, the right hand takes 
hold near the lock, and the left near the extremity of 
the handles, which are to be raised and turned over to- 
ward the symphysis pubis, until the pivot is vertical. 
The object here, as in the second situation, is to rotate 
the head, which brings the occiput or forehead under the 
symphysis, according as it is a second or fourth vertex 
position. After its rotation, the head is to be extracted, 
as in the first situation. 

The precept to rotate the head, in the second and 
third situations, notwithstanding its importance, must 
not be pertinaciously enforced in all cases, in defiance of 
the difficulties that may attend it. There are cases, and 
Baudelocque tells us he met with seven or eight, in 
which the head cannot be made to rotate without em- 
ploying more force than would be at all justifiable, as 
dangerous contusion of the maternal parts, or injury of 
the child's head, might be the consequence. In such in- 
stances, it is better to follow the advice of Baudelocque, 
and bring out the head in its diagonal position. Con- 
sidering that in the occipito-posterior positions of the 
vertex, it is more desirable that the occiput should ro- 
tate under the symphysis pubis than into the hollow of 
the sacrum, the suggestion was made long ago, and has 
been lately revived by Dr. Simpson, the distinguished 
professor of midwifery in the university of Edinburgh, 
that where the forehead is toward one of the acetabula, 
it should, in forceps deliveries, be rotated into the hol- 
low of the sacrum instead of the pubic arch. But 
though this might, in some cases, be safely executed, I 
doubt whether it would be proper, as a general rule, to 
attempt it; for notmthstanding the decided propension 



THE CROTCHET. 305 



to such a movement^ in ordinary and healthy parturi- 
tions, yet where the natural powers are enfeebled (as 
they mostly are when the forceps is used), art may take 
the shortest route, and turn the occiput toward the sa- 
crum, the rather because nature is not altogether unused 
to it, and the forceps will not be required to describe so 
large a segment of a circle, — an exercise not quite so 
innocent within the genital organs as upon paper. 

Secondly. Delivery hy the crotchet. 

The crotchet need not be particularly described. It 
is a sharp hook that is to be infixed in the cranium or 
face to extract the head, and necessarily mangles to 
such an extent as to destroy the child, if it be living 
when the operation commences. This mode of instru- 
mental dehvery should not, therefore, be resorted to un- 
less the cliild be dead, or if alive, the exigency be great 
and the forceps cannot be apphed. It ought not to be 
practiced, in any case, without first opening the head 
with a common perforator, both with the view of dimin- 
ishing its size, by removing the brain, and of preventing 
the shocking spectacle of a mangled child, whose vitality 
is not yet quite extinct. 

The reader cannot have failed to observe that, in de- 
hvering by the forceps, the operator is governed, fi*om 
first to last, by the mechanical laws that preside over 
the passage of the head; and that his success must de- 
pend upon his knowledge of those laws, and his conform- 
ity to their requirements. This is universally acknow- 
ledged : but it is not so generally known or considered, 
that, in delivering by the crotchet, close imitation of 
nature's movements is just as essential to the safety of 
20 



306 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



the operation as when the forceps is employed. To 
what but to efforts, not imitative but counteracting, can 
we ascribe the tremendous difficulty experienced by some 
practitioners in extracting the head, even after it is per- 
forated, and the brain removed, although no marked de- 
formity of the pelvis exists? I have listened to the recital 
of cases, in which so much difficulty was encountered, 
that the operator's own strength and tveight too were not 
sufficient to cause the head to hudge ( I ask pardon of 
Noah Webster), and he was compelled to call upon the 
midwife to lock her hands around his waist, and be 
clasped in hke manner by a third person, in order that 
by " a long pull, a strong pull, and a pull all together," 
the child might be brought to light ! No wonder that 
we so often hear of those deplorable cases of fistulous 
communications between the bladder or rectum and 
vagina, while such barbarous midwifery is tolerated, and 
men will undertake what they are not qualified to 
perform. 

Practitioners ought not, however, to be severely cen- 
sured for not doing what writers have generally failed 
to inculcate, — the sum of their instructions in regard to 
the extraction of the head amounting to this : that the 
crotchet must be infixed wherever the firmest hold can 
be had, or on some one part without regard to its eHgi- 
bleness, and the head be pulled along in the direction of 
the pelvic canal. To show that this is a fair statement 
of their instructions, let us look into authors, whose 
writings are more extensively diffused, and have con- 
tributed most to fashion the obstetric practice of 
our day. 

Dr. Smellie directs the fingers of the right hand 



THE CROTCHET. 307 



to be introduced above the os uteri and over the head, 
to conduct the crochet, held with the left hand, mth the 
point toward the child's head, which is to be fixed 
^' above the cliin^ in the mouth, hacJc ijart of tlie nedc, or 
above the ears, or in any place ivliere U thill take firm 
hold''{l). 

Dr. Denman du^ects the crochet, guided by the left 
hand, to be carefully introduced into the opening in the 
head, " and, fixing the point of the hook as far fi:om the 
edge of the bone as its curvature will allow, I begin," 
says he, " to pull moderately by the handle held in my 
right hand, guiding at the same time the hook of the 
crotchet with the fingers of the left, if it should happen 
to tear away the bone, or slip " (2). With his charac- 
teristic caution, patience, and perseverance. Dr. Den- 
man ^'ould continue to make tractions upon the head 
by this one hold, upon the principle that a degree of 
force, inadequate to overcome the resistance at first, will 
eventually succeed, " the resistance gradually diminish- 
ing, and the force remaining." Again, in cases of very 
great difficulty, where all the bones of the cranium have 
been brought away successively, and nothing of the head 
remains but the basis of the skull, with the integu- 
ments. Dr. Denman recommends the crotchet to be in- 
troduced again, " and fixed upon the basis of the skull, 
on any part where we can get a firm hold, and this as- 
suming a more convenient direction will be readily 
brought down. I have not found, in cases of this 



(1) Midwifery, Vol. I, book iii, chap. 3, sec. 7, number 4. 

(2) Introduction to the Practice of Midwifery, chapter 12, 
sec. 8. 



308 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



kind," he continues, " that I have acted from a prefer- 
ence for fixing the instrument in this or that part, or in 
this or that manner ; but giving myself time to reflect, 
the exigence of the case has dictated what I ought to 
do, so that I am not sohcitous about any particular 
method." 

According to Dr. Burns, the crotchet is to be intro- 
duced through the aperture of the cranium, " and fixed 
upon the petrous bone, or such projection of the sphe- 
noid bone, or occiput, as seems to afford a firm fixture " 
(1). Where the pelvis is so small as to require the 
head to be broken down, and nothing left but the face 
and base of the skull, he directs, of course, that this 
remnant be so placed as to bring its smallest diameter 
through the pelvis, by converting the case into a face 
presentation, with the root of the nose directed to the 
pubes. 

After stating that the crotchet may be applied either 
externally or internally, but that the latter, being the 
safer, is, on the whole, the better mode, Dr. Blundell 
observes, " I cannot designate or mark out to you, any 
one particular part of the head, as a bearing point, on 
which the instrument may be placed; but I may observe, 
that passing it into the cranial aperture with the right 
hand, and guiding it with the left, you may move it 
about until it fastens gn some part, either of the basis 
cranii, or of those bones which form the other parts of 
the receptacle for the brain " (2). The plain English of 



(1) Principles of Midwifery, American edition, with notes bj 
J. C. James, M. D., 1823, volume 1, p. 465. 

(2) Lectures, p. 279. 



« 



THE CROTCHET. 309 



Dr. Blundell's direction is, that you must get hold of 
the head wherever you can. 

Dr. Rigby advises that the crotchet be passed into 
the cranial cavity, and fixed upon some portion of the 
sJcull, affording a sufficiently firm hold for the purpose, 
the best spot being the petrous portion of one or the 
other of the temporal bones. We should never, accord- 
ing to him, try to fix it upon the " thin bones," that is, 
those composing the cranial vault, lest it slip or tear 
away, and he is equally opposed to Smellie's method of 
fixing it on the outside of the head (1). 

Dr. F. Ramsbotham prefers the very hold repudi- 
ated by Dr. Rigby, and directs the crotchet to be fixed 
on the internal surface of the bone, whenever there is 
sufficient resistance to afford the necessary purchase, ad- 
vising a finger of the left hand to be kept upon the head 
externally, exactly opposite the spot on which the ex- 
tremity of the instiument is fixed within, to receive its 
sharp point, should it break through the bone or slip 
fi-om its hold (2). 

Dr. Lee directs the point of the crotchet to be fixed 
on the inside of the head lehincl^ meaning on the part 
which corresponds with the hollow of the sacrum, at as 
great a distance as possible from the opening in it made 
with the perforator, and the fingers of the left hand to 
be so arranged as to form a double crotchet ; and if the 
point of the crotchet tear away, he advises that it be 
placed upon another pm^t of the hones of the head (3). 

(1) Midwifery, p. 260. 

(2) Process of Parturition, new Araer. edition, p. 213. 

(3) Lectures on tlie Theory and Practice of Midwifery, p. 
306. 



310 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



But let US look into the work of Dr. Dewees, who 
had undoubtedly more influence in shaping and regula- 
ting the practice of this country than all the British au- 
thorities whom we have quoted. After expending six- 
teen pages on a critical disquisition, of no practical 
value, he observes, very briefly, that "the mode of per- 
forming embryulcia is sufficiently simple, if we merely 
regard the opening of the head, and the breaking down 
the texture of the brain; but the extraction of the 
bones in a confined pelvis is replete with difficulty," and 
then, having explained the manner of opening the head, 
he says, "the point of the crotchet is to be fastened in 
the nearest portions of hone " (1). 

It might have been expected that Dr. Dewees, who 
gloried in being a follower of Baudelocque, would have 
at least equalled his great prototype, in the propriety 
and precision of his directions for extracting the head. 
What says Baudelocque ? "To obtain the success we pro- 
pose, it is not a matter of indifference where the crotchet 
is applied. In fixing it upon the superior margin of the 
orbit, or upon the petrous portion of the temporal bone, 
as the greatest number of ancient and modern practi- 
tioners have done, the head is made to advance by pre- 
senting its greatest diameter, and is thrown upon the 
back or one of the shoulders of the child ; it cannot 
then be extracted without mutilating it and evacuating 
the brain, even though its size be not disproportioned to 
the pelvis. It is upon the occiput that the crotchet 
must be implanted when the head is the presenting 
part, and upon the superior maxillary bone, or the fore- 

(1) Midwifery, p. 561. 



THE CROTCHET. 311 



head, when we are obliged to use the instrument in 
cases of preternatural presentations, after the trunk is 
dehvered. In acting thus, we shall cause the head to 
descend, offering one of its extremities and only its 
smallest diameter throughout the whole of the opera- 
tion. We must, moreover, have regard to the particular 
direction which the head should follow, in each of its po- 
sitions, in order that it may traverse the pelvis with the 
least possible difficulty" (1). 

I have translated the whole of Baudelocque's para- 
graph in relation to the extraction of the head with the 
crotchet, because I believe it is worth more than all that 
has been written on the subject, and, for one who under- 
stands the mechanism of labor, embodies all that need 
be said concerning it. Its value might be illustrated 
in a great variety of ways, with one of which only I 
shall content myself, leaving the thoughtful reader to 
supply as many others as he pleases. Suppose it be- 
comes necessary to dehver with the crotchet, in a case 
of occipito-posterior position of the vertex : if the point 
of the instrument be infixed into the anterior part of the 
base of the skull, who does noc perceive that by draw- 
ing upon it, the opposite to nature's movement will be 
forced on the head ? The extra-flexion will be defeated, 
and a degree of extension be produced, bringing the oc- 
cipito-frontal diameter down into the pelvis first; and, if 
the mad attempt be persisted in and brute force usurp 
the place of skill, subsequently the axis itself of the 
head. Who can think of the head being thus dragged 
through the pelvis, without shuddering, and wondering 

(1) L'Art des Accoucliemens, par. 1924. 



312 SPECIAL TREATMENT OF VERTEX PRESENTATION. 



if the bladder and rectum can preserve their integrity, 
in spite of such enormous violence ! 

I will only observe further, in concluding this chap- 
ter, that notwithstanding the marked preference, which 
most authors manifest, for applying the crotchet upon 
the interior of the skull, it is generally most advisable 
to apply it exteriorly, because we can thus obtain the 
firmest hold, and apply it more readily to such part of 
the head as maybe demanded by its particular position, 
and also by what remains to be executed of its mech* 
anism. 



NATES PRESENTATION. 313 



CHAPTER XYII. 

NATES PRESENTATIONS — THEIR MECHANISM, DI- 
AGNOSIS, AND PROGNOSIS. 

It was remarked, in a former chapter, that under 
the common denomination of "nates," are included pre- 
sentations of the breech, feet, and knees, which are only 
modifications of one great class, viz., presentation of the 
pelvic extremity of the fetus. When the child presents 
thus, it may be, as M. Cazeaux observes, 1. That the 
pelvic extremity, composed of all its elements, viz., the 
thighs flexed upon the abdomen, and the legs upon the 
thighs, engages in the excavation and in the inferior 
strait ; 2. That the inferior extremities, floated by the 
liquor amnii, after the rupture of the membranes, deploy 
in whole or in part, causing the feet or the knees to 
reach the vulva first; 3. That the legs becoming ex- 
tended and brought into apposition with the anterior 
plane of the fetus, the breech alone descends ; 4, and 
lastly. That one of the inferior extremities may be ex- 
tended upon the abdomen, while the other is deployed, 
and thus one foot or knee only may present at the 
vulva. 

It is manifest that these modifications cannot mate- 
rially affect the process of expulsion, and it were, there- 
fore, worse than useless to describe the mechanism of 
each of them. It wUl be sufficient for our purpose to 



314 SPECIAL PHENOMENA OF SECOND STAGE. 



take the most common modification, namely, that in 
which the breech alone engages in the pelvis, the infe- 
rior extremities being extended upon the abdomen of 
the fetus. 

1. Mechanism of the first or left dor so-iliac position of 
the nates. 
In this position, the back of the fetus looks toward 
the left side of the mother, its anterior plane, that is^ 
abdomen, breast and face, is toward the right, its left 
side is forward, and its right side backward. 

First step — descent of the breech.— If the breech 
be not large, it engages in the superior strait as it offers 
itself, viz., with the bisiliac diameter parallel with the 
sacro-pubic diameter. But if it be too large to engage 
thus, it undergoes a preparatory rotation, which brings 
its bisiliac diameter parallel with the right oblique 
diameter of the strait. In its descent into the pelvic 
cavity, the breech moves in the dh'ection of the axis of 
the superior strait, that is, downward and backward, 
and consequently the left or anterior hip is considerably 
below the symphysis pubis, when the right or posterior 
hip is in the hollow of the sacrum. 

Second step — rotation. — Arrested by the posterior 
wall of the excavation, the breech is compelled to move 
in the direction of the axis of the inferior strait ; pre- 
paratory for this, if the breech be obliquely situated in 
the pelvis, rotation takes place, which brings the left 
hip under the symphysis pubis, and the right into the 
hollow of the sacrum. If the breech have engaged in 
the pelvis with its bisiliac diameter parallel with the 
sacro-pubic, without any rotation, one hip is, of course. 



NATES PRESENTATION. 315 



anterior aud the other posterior, when it reaches the 
inferior strait. 

Third stejj — disengagement.— T\iq left hip now en- 
gages under the symphysis pubis and makes its appear- 
ance first at the vulva, where, continuing stationary, it 
becomes the pivot upon which the right hip moves, de- 
scribing an arc of a circle, as it sweeps over the con- 
cavity of the sacrum, coccyx, and perineum, to be com- 
pletely released before the left hip is. While the hips 
are passing out in this manner, the trunk is necessarily 
incurvated upon its left side, and as soon as they have 
cleared the vulva, the left hip turns toward the right 
thigh of the mother, if the breech had been obliquely 
situated in the pelvis, — otherwise it continues anterior 
and the right hip posterior. 

Fourth step — passage of the trunJc. While the 
trunk is passing through the pelvis, its flexibility allows 
it to be conformed to the curvature of the canal, and it 
continues, therefore, to be incurvated upon the left side, 
which is toward the pubes. The shoulders engage in 
the superior strait diagonally, the bisacromial diameter 
corresponding to its right oblique diameter, and the 
arms continue to be closely applied to the sides and the 
forearms crossed upon the breast, unless the child is very 
large, when the elbows may be intercepted at the supe- 
rior strait, and the body continuing to descend, the arms 
be carried up alongside the head. At the inferior strait, 
the shoulders rotate, the left passing toward the pubes, 
and the right tovrard the hollow of the sacrum, when the 
left shoulder presses against the inner face of the pu- 
bes, while the right moves over the concave surface of 
the sacrum, coccyx, and perineum, and is first extrica- 



316 SPECIAL PHENOMENA OF SECOND STAGE. 



ted, drawing down the arm after it, if it had been car- 
ried upward. Then follows the extrication of the left 
shoulder and arm from^under the pubes. As the shoul- 
ders pass, if not sooner, the feet arrive at the vulva, and 
as soon as they are released, the inferior extremities are 
extended and the child is undoubled. 

Fifth step — Passage of the Head. — The head ap- 
proaches the superior strait, offering the occipito-frontal 
diameter to its left oblique diameter ; but pressed by 
the uterine contractions, it flexes so as to have substi- 
tuted for this, a diameter approximating the cervico- 
bregmatic. Entering the excavation thus, a rotation 
similar to that of vertex positions conducts the face 
into the hollow of the sacrum, the occiput behind, and 
the nucha under, the symphysis pubis. At this time 
the uterus can act but feebly on the head, which is 
partly or wholly in the vagina, but the contractions of 
the abdominal muscles, aroused by pressure on the rec- 
tum and bladder, come to its aid, and their united force 
produces increasing flexion of the head. The center of 
this flexion movement is the junction of the nucha with 
the occiput, which is stationary under the symphysis pubis, 
while the chin, the forehead, the bregma, and occiput, suc- 
cessively pass out before the perineum. While it is being 
performed, the head, as M. Cazeaux remarks, represents 
a lever of the first kind, the power being at the occiput, the 
prop at the cervico-occipital junction, and the resistance 
at the chin, and especially the forehead, which are to be 
depressed. If, as he further observes, radii be drawn 
from the cervico-occipital point, under the symphysis 
pubis, to various points of the median line of the face 
and cranial vault, these radii will exactly represent the 



NATES PRESENTATION. 317 



diameters that successively clear the antero-posterior di- 
ameter of the inferior strait, the principal of which are the 
cervico-mental, cervico-frontal, and cervico-bregmatic. 
In other words, flexion places the axis of the head parallel 
with the axis of the inferior strait, and then its lesser cir- 
cumference is offered to the aperture of the inferior 
strait. 

2. 3Iechanism of the second or right dorso-iliac position 

of the nates. 
In this position, the relative situation of the several 
parts of the fetus is the reverse of what obtains in the 
first, but the mechanism of labor is essentially the same. 
It marches to its consummation by the same steps: the 
breech turns its bisiliac diameter to the left oblique di- 
ameter of the superior strait, if it be too large to enter 
directly ; when it gets to the bottom of the pelvis, the 
right hip rotates toward the symphysis pubis ; in clear- 
ing the inferior strait, the right hip appears first exter- 
nally under the pubes, but the left comes out first before 
the perineum ; when the shoulders enter the pelvis, 
then* bisacromial diameter parallel with its left oblique 
diameter, the right shoulder rotates behind the pubes, 
where it remains until the left clears the vulva by mov- 
ing over the concavity of the sacrum, coccyx, and peri- 
neum; the head, finally, presents its occipito-frontal 
diameter to the right oblique diameter of the superior 
strait, flexes as it enters, rotates in the excavation, 
throwing the face into the hollow of the sacrum and the 
occiput behind the pubes, and then, under increased 
flexion, the chin, forehead, bregma, and occiput are suc- 
cessively born. 



318 SPECIAL PHENOMENA OF SECOND STAGE. 



3. 31echamsm of the third or dorso-piibic position of 

the nates. 
In this position the back of the fetus looks directly 
forward, its anterior plane, with the inferior extremities 
doubled upon it, looks directly backward, its right side is 
toward the left of the mother, and its left side toward 
the right. The same steps belong to its mechanism as 
to that of the first and second, only they are a little 
varied to suit its circumstances. Thus, the breech 
plunges into the pelvic excavation, with its bisiliac 
diameter parallel with the transverse diameter of the 
superior strait, and when it reaches the floor of the pel- 
vis, either hip indifferently may rotate forward, but 
rotation is not usually carried farther than to place the 
hips in one of the oblique diameters of the inferior strait, 
and the breech passes out in this oblique manner, the 
hip that is most forward appearing first, but that which 
is posterior being completely expelled before it. The 
passage of the shoulders is the same as that of the hips, 
and the head escapes as in the first and second positions. 

4. Mechanism of the fourth or dor so-sacral position 

of the nates. 
The relations of the fetus to the mother in this po- 
sition are the reverse of what they are in the third, and 
its mechanism is considerably, and may be materially, 
different. The difference pertains chiefly to the manner 
in which the head is transmitted through the pelvis. 
The occiput may remain posterior until the head is com- 
pletely expelled, or, what more frequently occurs, it 
may come forward and be placed behind the symphysis 
pubis. 



NATES PRESENTATION. 319 



1. Revolution of the occiput fornvard. — This, as 
M. Cazeaux remarks, may commence with the disen- 
gagement of the hips, the trunk and head participating 
in the rotatory movement, which begins with them and 
is extended to the occiput, so that the child descends 
spirally, and by the time the head reaches the excava- 
tion, the occiput is brought behind the pubes. But this 
transmutation of the head may take place even after it 
is lodged in the excavation, and the trunk is entirely 
expelled, with the back still directed posteriorly. The 
head is then placed diagonally in the pelvis, the occiput 
being at the posterior extremity of one of its oblique 
diameters, and the forehead at its anterior extremity. 
It executes a rotatory movement, b}^ which the occiput 
revolves forward from one of the sacro-iliac symphyses 
to the pubes, while the forehead roUs backward into the 
hollow of the sacrum. When the occiput is once 
placed behind the symphysis pubis, whether in one or 
the other of the modes now described, the labor is ter- 
minated in the same manner as in the preceding positions. 

2. The occijout maintains its posterior station. — In 
this situation, the head may be disengaged in two ways. 
According to the first, which is most common, the head 
enters the excavation under decided flexion, and soon 
undergoes rotation which deposits the occiput in the 
hollow of the sacrum, and the forehead behmd the sym- 
physis pubis. It is then extricated by being forced to 
become more and more flexed, and as flexion proceeds, 
the face, forehead, vertex, and occiput successively ap- 
pear beneath the symphysis pubis. The center of this 
movement is the nucha resting upon the anterior com- 
missm^e of the perineum. 



320 SPECIAL PHENOMENA OF SECOND STAGE. 



According to the second and rarer method, the head 
becomes extended on entering the pelvis, in consequence 
of which the chin rises above the pubes, while the occi- 
put is retroverted. This extension is carried to its ut- 
most limit, causing the face to look toward the superior 
strait, while the occiput is depressed along the posterior 
wall of the excavation, and is first disengaged before the 
perineum, to be followed by the vertex, forehead, and 
face. The center of this movement is the guttural 
fossa, bearing upon the under part of the symphysis 
pubis. 

Whether the head be disengaged in one of these 
modes or the other, it is released from the pelvis with 
much more difficulty than when the face is turned into 
the hollow of the sacrum. The difficulty was formerly 
attributed to the chin getting hooked upon the superior 
border of the pelvis, and rules were prescribed for pre- 
venting such an accident. Baudelocque was right in 
rejecting such an unfounded explanation, but that which 
he substituted, though not so chimerical, is not more 
satisfactory. He supposed the difficulty to be owing 
to the forehead and vertex being too broad to pass un- 
der the symphysis pubis, the narrowest portion of the 
pubic arch. A more correct rationale will be found by 
adverting to the fundamental principle, governing the 
head's transmission ; for, a moment's reflection will show 
that in the actual position of the head, it is not possible 
for its axis to become parallel with the axis of the in- 
ferior strait, but it continues oblique — whether the head 
be flexed or extended, more so in the latter than in the 
former case, — and therefore not its lesser circumference, 



NATES PRESENTATION. 321 

but one approaching the greater, is offered to the inferior 
pelvic aperture. 

Explanaiory and critical remar'ks. 

Although I have described the hips as rotating, the 
one under the symphysis pubis and the other into the 
hollow of the sacrum, in the first and second nates po- 
sitions, it is not to be understood that this takes place 
in every instance, or even perhaps in a majority of 
cases. The rotatory movement is fi:equently, if not 
most commonly, only partial, bringing the hip that is 
anterior (the left in the first, and the right in the second, 
position) under the corresponding ramus of the pubes, 
where it remains until the posterior hip is expelled, the 
breech preserving a certain degreee of obliquity as it is 
passing through the inferior aperture of the pelvis. It 
is not, however, without the warrant of high authorities 
that I have assumed complete rotation to be a part of 
the regular mechanism of these positions; it is so de- 
scribed by Gardien, Capuron, Duges, and more recently 
by Moreauand Cazeaux,— the latter, however, affirming 
that the hips pass the bony outlet of the pelvis some- 
what obliquely and become directly antero-posterior, as 
they pass through the vulva. As we cannot suppose 
that these eminent practitioners were all deceived, on 
this point, we are bound to conclude that such complete 
rotation is no uncommon occurrence ; and I adopt it as 
the regular procedure, for the purpose of placing the 
mechanism of these positions in contrast with that of 
the thnd and fourth, looking at the directness of the 
former and the oUiqidty of the latter. 

The more or less oblique passage of the hips is de- 
21 



322 SPECIAL PHENOMENA OF SECOND STAGE. 



scribed by Baudelocque as the regular mechanism of the 
first and second positions of the nates — I say more or 
less obhque^ for Baudelocque makes a difference in de- 
gree between the same position of the feet and breech, 
affirming that in the first position of the feet, as soon as 
they are born, the breech appears at the vulva, almost 
always in a diagonal situation, the left hip correspond- 
ing to the right leg of the pubic arch, and the right hip 
to the left sacro'ischiatic ligament: he adds that the 
breech cont.nues to advance in this direction, rising 
slightly toward the mons veneris, as the trunk is disen- 
gaged (1); while of the corresponding position of the 
breech, he says, as it descends, its greatest dimension (bis- 
iliac diameter) hecomes almost parallel with the antero- 
posterior diameter of the inferior strait, the left hip 
I eing placed a little oUiquely under the puhes, and the 
right before the sacrum (2). 

Madame Lachapelle testifies to the frequency of the 
more or less obhque passage of the hips. She even af- 
firms that the most usual course is for one hip to pass 
out under one branch of the pubic arch, and the other 
along the opposite sacro-ischiatic ligament (3). 

This admirable writer makes, moreover, some very 
judicious reflections upon the mechanism in general of 
nates presentations, observing that it is far from being 
as uniformly the same as that of the different regions of 
the head, nor are its steps and movements as distinct 
and well-defined. On account of the softness of the 
parts constituting them, nates presentations accommo- 
date themselves more easily to the different forms of the 

(1) Par. 730 

(2) Par. 770. 

(3) Pratiq^ue des Accouchemens, Quatrieme Memoire. 



NATES PRESENTATION. 323 



straits; they are readily molded, and have, consequent- 
ly, less occasion to change their direction to acquire the 
most advantageous relations with the great diameters of 
the straits and excavation. If, as she truly observes, 
the head were soft enough to be conformed to the con- 
figuration of the different parts of the pehis, its mech- 
anism would be null, at least as far as rotation is 
concerned ; nothing would remain but the movements 
dependent upon the difference between the axes of the 
two straits. This is almost hterally true of the nates: 
the hips and even the shoulders may traverse the straits 
in any wise, save with then' great diameter, the child 
being large, directed antero-posteriorly at the superior 
strait, or transversely at the inferior. The head alone 
must, of necessity, pursue the same march as in vertex 
cases, in order that it may escape. 

Professor Nsegele subjects nates presentations fully 
to the dominion of his obhque theory of parturition. 
In the essay, which has been already several times 
quoted, he reduces these presentations to the two fol- 
lowing species, viz., 1. Presentation of the nates with 
the back turned forward, toward the anterior parietes of 
the uterus. 2. Presentation of the nates with the back 
turned toward the posterior parietes of the uterus; re- 
marking, however, that the back of the child, at the 
beginning of labor, is usually turned more or less side- 
ward, the ischia running parallel with one or the other 
of the obhque diameters of the pelvic entrance. In 
either species and in every case, he maintains, the hips 
pass through the entrance, caviiy, and oidlei of the pelvis 
in this oblique position; the shoulders follow in like man- 
ner, and lastly the head, entering obliquely, sinks into 



324 SPECIAL PHENOMENA OF SECOND STAGE. 



the excavation in the same direction, or with its occipi- 
to-frontal diameter "more approaching the conjugate 
diameter." "After this," says he, "it passes through 
the external passage and the labia in such a manner, that 
while the occiput rests against the os pubis, the point 
of the chin, followed by the rest of the face, sweeps 
over the perineum, as the head turns on its lateral axis 
from below upward." 

Drs. Rigby and Churchill fully adopt the views of 
the German teacher, in relation to the obhquities of the 
nates as well as the head; but Dr. Maunsell revokes as 
to the disposition of the head in nates cases, which, he 
allows, is turned with the face into the hollow of the sa- 
crum. 

From the statements which have now been made, it 
appears that the oblique theory of parturition, as far as 
nates presentations are concerned, has not even the 
merit of novelty, except in affirming, that what is ob- 
served, in many instances, is universally true. 

There is one interesting, and, practically considered, 
important feature of nates presentations, only slightly 
alluded to as yet, which deserves to be exhibited in 
higher relief; I mean the strong tendency of the hack 
imrts of the childy in the dorso-posterior position^ to re- 
volve forward so as to hring the occiput toivard the pub es 
as the head engages in the pelvic cavity. 

For the promulgation of this important truth, and 
its ameliorating influence upon the management of nates 
presentation, we are indebted to Professor Nsegele, to 
whom it gives me pleasure to ascribe all just praise. 
Baudelocque describes the head as entering the pelvis, 
in this position, with the forehead directed to one of the 



NATES PRESENTATION. 325 



acetabula at first, but rotating afterward under the pu- 
bis; and he does not, as far as I can discover, hint at the 
possibihty of a different course. But Nc^gele affirms, 
more truly, that after the hips pass out along one of the 
oblique diameters, the anterior surface of the child turns 
first toward the pubes, and then backward, either imme- 
diately, or as the rest of the trunk advances; and that 
the manner in which the head presses through the en- 
trance, cavity, and outlet of the pelvis, is the same as 
in the other positions. He mentions a remarkable fact, 
which shows the strength of the tendency to this aus- 
picious revolution of the child's body, ^dz., should the 
anterior surface of the body continue to be directed 
obliquely forward, even until the shoulders engage in 
the pelvis, it may yet turn fi'om the side completely 
forward, and then to the opposite side, during a single 
pain by which the shoulders are expelled ; and this ex- 
tensive rotation of the body, wliich brings the head so 
much more favorably into the pelvis, may take place 
" in the twinkling of an eye " (1). That this change 
does not, however, always occur, even N^gele admits, 
and the experience of others abundantly confirms : 
hence the propriety of recognizing posterior, in contra- 
distinction fi:om anterior, positions of the nates as well 
as of the vertex. 

Diagnosis, 
Considered in a diagnostic point of view, nates pre- 
sentations possess several characters in common, but 
they differ, also, fi-om each other much more than in re- 

(1) 3Iecbanism, p. 137. 



326 SPECIAL PHENOMENA OF SECOND STAGE. 



spect to their mechanism. We may, therefore, consider 
first the signs which denote nates presentation in gen- 
eral, and afterward point out the marks which serve to 
distinguish its three modifications, viz., presentation of 
the breech, feet, and knees. Among the signs of nates 
presentation, those most to be rehed on are the following : 

1. The form of the abdomen. — It is sometimes 
the case, particularly in lean women who have borne 
children before, and in whom the abdomen is conse- 
quently relaxed, that we are able to feel the head of 
the child, more or less distinctly, at the fundus of the 
uterus, and inclined toward one side. If we are not 
able to define the head satisfactorily, we may neverthe- 
less feel the prominences formed by it and the shoul- 
ders, giving to the upper part of the womb an irregu- 
larity not observable when it is occupied by the nates. 
The evidence then is, however, reduced to greater or 
less probability. 

2. Hearing the fetal hearfs action above the iimbili- 
ciis. — The sounds produced by the action of the fetal 
heart are transmitted through the posterior and supe- 
rior part of its thorax, and heard mostly in whatever 
region of the mother's abdomen this part may be oppo- 
site. These sounds are consequently detected, in cases 
of vertex presentation, in the inferior lateral, but sel- 
dom in the umbihcal, region of the abdomen; and if 
they are distinctly heard in such high region and not 
in the lower, strong proof will be afforded that the nates 
are situated toward the pelvis of the mother. Dr. 
CoUins assures us that he has not unfrequently diag- 
nosed the presenting of the breech or inferior extrem- 
ity, before there was any appearance of labor, by attend- 



NATES PRESENTATION. 327 



ing to this sign alone; and he observes, with his usual 
judiciousness, that a knowledge of it may assist us 
where we are doubtful as to the presenting part; but 
until the os uteri is considerably dilated, little practical 
benefit, further than putting us on our guard, can be 
derived from it (1). "In cases of breech presentation," 
Dr. Kennedy remarks, "the fetal heart's action is ob- 
served higher up, and according to the state of advance- 
ment of labor at the time of appl}ang the stethoscope, 
above or below the umbilicus " (2). Let it be remem- 
bered, however, that when the back of the fetus is 
turned forward ( as it most frequently is after labor be- 
gins ), and comes in contact with the abdominal parietes, 
then, according to the observation of the author last 
quoted, the fetal pulsation is sometimes heard extend- 
ing from two or three inches above the umbilicus, over 
the whole of the anterior part of the abdomen, inclining 
to one or the other side, according to the position of 
the back of the fetus. This extension of the sound re- 
sults from the heart being brought nearer the surface, 
and the proximity of the back to a good conductor. 
When thus diffused, it is not equally distinct over the 
whole space, but will be most plainly heard near the 
maternal umbilicus ; whereas the point of its greatest in- 
tensity, in vertex presentations, is in one of the ihac 
regions. 

3. The form of the membraneous c?jst and cf the 



(1) Practical Treatise on Midwifery, Boston edition, 1841, 
p. 30. 

(2) Observations on Obstetric Auscultation, New York edi- 
tion, 1843, with notes by Dr. J. E. Taylor, p. 268. 



328 SPECIAL PHENOMENA OF SECOND STAGE. 



orifice of the uterus. — It is an old observation, that 
when the breech presents, the membranes protrude at 
the OS uteri in an oval form, and when the feet present, 
depend in an elongated form, resembhng a purse. The 
observation is not without some foundation, but the 
form as well as the extent of the cyst is much more 
influenced by other circumstances, such as the shape of 
the orifice, the density of the membranes, the quantity 
of Hquor amnii, etc. 

The oval form of the uterine orifice, after the mem- 
branes rupture, appears, however, to be entitled to more 
notice. This is caused by the oval figure of the breech, 
which, being propelled into the cervix by the contrac- 
tions of the body of the uterus, makes it conform to its 
figure, and consequently the long diameter of the orifi- 
cial oval corresponds to the hips of the child. 

4. The elevation of the presenting fart\ making it 
difficult to he reached ivhile the membranes are whole, 
and the unusual flow of the waters after the rupture of 
the membranes. — The breech, with its appendages, con- 
stituting nates presentation, offers a volume so consid- 
erable that it does not easily engage in the superior 
strait. It remains, therefore, so high in the pelvis, al- 
though labor may have lasted a considerable time, as to 
be beyond the reach of the finger, or only accessible to- 
ward the pubes. Meanwhile, the formation of the mem- 
braneous pouch, and the gathering of the waters'beneath 
the nates, increases the difficulty of satisfactorily deter- 
mining the nature of the presentation, even after the os 
uteri is amply dilated. If the presenting part stiU re- 
main high for a time, notwithstanding the rupture of 
the membranes, and more especially if there be a great 



NATES PRESENTATION. 329 



gush of liquor amnii, which continues to flow during the 
pains, even after the orifice is occupied, the probabHity 
is strong that it is a nates presentation. The reason of 
the continued escape of the Uquor amnii was correctly 
assigned by Mauriceau, who was also well aware of the 
disadvantages of the entire depletion of the uterus, re- 
sulting from it (1). The liquor amnii runs off through 
channels left by the inequalities of the presenting parts; 
if the feet or knees present, they are too small to ob- 
struct the orifice; if the breech offer, the water flows 
between the thighs; whereas when the head presents, 
its volume and regular roundness fit it to act as a com- 
plete stopper. 

Although these signs usually accompany nates pre- 
sentation, we shall be liable to err in our diagnosis, if 
we rely too implicitly upon them. Most, if not all, of 
them may be present, and yet the vertex may prove to 
be the presenting part. Of this I had a very interest- 
ing illustration, quite recently, in the case of an Msh 
woman, who had been in labor all night previous to my 
seeing her, early in the morning. The membranes were 
entire, and formed a large projection into the vagina, but 
the margins of the os uteri could nowhere be felt, it 
was so completely dilated and withal attenuated. Du- 
ring the pains, it was impossible to feel anything but 
the tense globe of waters : in the intervals, I could, by 
pushing the finger very high, barely touch something 
solid just behind the top of the symphysis pubis. I ap- 
prehended a nates presentation; but to clear away all 



(1) Traite des Maladies des Femmes Grosses, Livre II,_Cbap- 
ter 13. 



SPECIAL PHENOMENA OF SECOND STAGE. 



obscurity, as well as to fulfill a practical precept hereto- 
fore inculcated, I ruptured the membranes by pressing 
the point of the finger firmly against them during a pain. 
This was followed by such a rush of waters as I have 
rarely witnessed, and the flow continued very free, du- 
ring subsequent pains, until the patient was completely 
drenched. The presenting part meanwhile slowly de- 
scended, and proved to be the vertex. The child, a 
female, was born, in two or three hours, completely 
asphyxiated, but was recovered by the usual means. 

5. Discharge of the meconium. — This affords a sign 
which must be considered as pretty conclusive, provided 
we do not allow ourselves to be deceived by its counter- 
feit, — I refer to the discharge of meconium, which is li- 
able to occur in head presentations, when the fetus is 
dead, or in a suffering condition. In that case, the me- 
conium is diluted by m^ixture with the uterine and va- 
ginal discharges, and is altogether different from the 
thick, viscous, and tarry excrements, issuing directly 
from its repository. All the signs common to nates 
presentation, which have now been enumerated, are 
more or less fallacious, and our diagnosis can seldom be 
entirely satisfactory until it is enlightened by the touch, 
and we can never otherwise determine the position of the 
presenting part. With regard to the marks discoverable 
by the touch, the several modifications of nates presen- 
tations differ so much that it is necessary to consider 
them separately. 

The hreech, when engaged in the pelvis and suffi- 
ciently accessible to the finger, is distinguished from 
every other part of the child, by marks so characteris- 
tic that it is not easily mistaken. These are, its fleshy 



% 



NATES PRESENTATION. 331 



feel, and its two gluteal prominences, with an intervening 
depression in which may be felt the point of the os coc- 
cygis^ — surmounted by the unequal posterior surface of 
the sacrum, — the anu8^ — -differing from any other ori- 
fice in its thin, puckered, circular margin, and small size, 
requiring, indeed, to be forced before it will allow the 
finger to penetrate it, — and lastly, the genital organs. 
It must be remembered that in by far the most usual 
positions of the breech, with the sacrum to one side or 
the other of the pelvis of the mother, the finger first en- 
counters the hip that is anterior, which might be mis- 
taken for the head, if the examination is not prosecuted, 
for this hip offers a roundish surface of considerable ex- 
tent, and anteriorly the trochanter major feels hard and 
resisting. But on passing the finger as deeply as possi- 
ble, and curving it forward, as in searchmg for the sagit- 
tal commissure in a vertex case, the cleft of the breech 
may be reached, and what is felt there, as already de- 
scribed, will clearly reveal the nature of the presenta- 
tion. The direction of this cleft and the situation of the 
coccyx point out the position of the breech. Thus, it 
runs transversely in the first and second positions, the 
coccyx being toward the left side of the pelvis in the 
first, and toward the right in the second: it runs ante- 
ro-posteriorly in the third and fourth positions, the coc- 
cyx being forward, in the third, — where it and a good 
part of the sacrum can be easily felt, — and backward in 
the fourth. 

Let none imagine, however, that it is always an easy 
matter to ascertain how the breech is situated, or even 
to recognize itself when it is presenting. Previous to 
the rupture of the membranes, it may be placed too 



332 SPECIAL PHENOMENA OF SECOND STAGE. 



high, or be too obscurely felt; and, after the escape of 
the waters, it may be so disfigured by tumefaction, fi'om 
long detention in the pelvis, that its natural features are 
obliterated. In this latter condition, Baudelocque in- 
forms us, the best-instructed practitioners have mistaken 
it, for one part and another, even for the head of the 
child, the integuments of which were supposed to be 
engorged and swollen. A very celebrated accoucheur, 
he states, having mistaken the breech under such cir- 
cumstances for locked head, applied the forceps success- 
fully, and considered the mistake fortunate, as it taught 
him a new resource in dilficult breech presentations (1). 

But, it may be said, how much soever the breech 
may be deformed by swelHng, the anus is so character- 
istic it ought to be sufficient to prevent such mistakes. 
Aye, so it ought, if it ^YeYe always found a closed and 
puckered orifice ; but if the child be dead, and a curious 
examiner have been poking at it before we are called, it 
may be gaping and tumid, and feel like the mouth, 
while the buttocks, to the touch alone, are not unlike 
the cheeks. No wonder then if it should be mistaken 
for a face presentation, one instance of which is within 
the compass of my own knowledge, — in sooth, magna 
pars fid. 

Madame Lachapelle relates that such a mistake was 
committed by a veteran professor of VEcole de Ifededne, 
under circumstances that rendered it as ludicrous as 
notorious. He assured the pupils, who were present 
during an accouchment v/hose progress he was watching, 
that he recognized the face, and had even put his finger 

(1) Par. 1262. 



NATES PRESENTATION. 333 



in the child's mouth, nothwithstanding that this same 
finger, covered with meconium, and extended toward 
the pupils in gesticulating, flatly contradicted what he 
was announcing. 

When thQ feet present and can be fairly examined, 
they ought to be distinguished fi^om the hands by at- 
tending to the following marks ; the toes are short, of 
nearly equal length, and but slightly movable ; the 
fingers are long, flexed upon the palm, may often be 
felt to contract, and the thumb is more separated from 
the rest ; the internal margin of the foot is thicker than 
the external ; the two margins of the hand are of nearly 
equal thickness ; the foot forms a right angle with the 
leg, the hand a continuous fine with the arm. While 
the feet are high in the pelvis, and before the membranes 
rupture, they may be mistaken for some other part, or 
we may experience momentary uncertainty. The feet 
are naturally flexed upon the leg, and it may be that 
only the heel is accessible, w^hich may then be taken 
for the elbow, which it very much resembles in form, as 
Madame Lachapelle observes, the heel being like the 
olecranon, and the malleoli like the condyles of the hu- 
merus. Under this delusion, it is easy for any one, as 
she justly remarks, and I myself have experienced, to 
imagine that the breech which is felt just above the foot 
is the thorax, and conclude in favor of a shoulder pre- 
sentation. Such an error cannot, however, be of long 
duration, and if not corrected before the membranes 
rupture, must be discovered shortly after that event. 

It is not always easy to form a correct diagnosis as 
to the position of the child in nates presentations, when 
this must be determined by examining the feet alone, 



334 SPECIAL PHENOMENA OF SECOND STAGE. 



the breech being too high to admit of satisfactory ex- 
ploration. If both feet are down in the vagina, the di- 
agnbsis is, of course, perfectly plain, for the heels cor- 
respond to the back of the child, as constantly as does the 
sacrum, when the breech is lowermost. The heels being 
toward the left side of the pelvis, then, indicate the left 
dorso-ihac position, toward the right, the right dorso-iliac 
position, etc. If the feet are yet contained in the ute- 
rus, or even in the membraneous sack, and both can be felt 
parallel with each other, the heels still point directly to- 
ward the back of the child and indicate its position. 
But if they are crossed upon the breech and the toes 
turned inwardly, so that the toes of each are near the 
heel of the other, — a disposition by no means infre- 
quent, Madame Lachapelle says once in three cases, — we 
may be confounded at first in our attempts to make out 
the position, but with care we shall succeed. We have 
only to take either foot, and ascertain to which side of 
the fetus it belongs, which may be done by attending, as 
M. Cazeaux directs, to the relation existing between its 
internal margin and heel, and different points of the 
pelvis of the mother. Let us suppose, wdth him, that 
the heel is turned toward the symphysis pubis, and the 
internal margin toward the right side of the mother, it 
is evident that it is the right footj if, on the contrary, 
the heel be toward the sacro-vertebral angles and the 
internal margin toward the right, it is the left foot, etc. 
Another means of determining whether it be the right 
or left foot we are examining, I will venture to suggest; 
it is the same recommended for finding which hand has 
prolapsed in shoulder presentations, though no writer, as 
far as I know, has directed it for the foot : aj ply the 



NATES PRESENTATION. 335 



palm of your hand to the sole of the foot, the fingers ex- 
tending toward the heel ; if it be your right hand and 
the great toe corresponds to the thumb, it is the right 
foot ; if the little toe corresponds to the thumb, it is the 
left foot. The literal application of the palm to the sole 
is not necessary ; if the extremities of the fingers are 
directed toward the heel, it is altogether sufficient. 

Having distinguished which foot it is we are exami- 
ning, we have only to notice toward what part of the 
pelvis the toes point, in order to determine the position 
of the fetus. If, for example, it be the right foot ( still 
borrowing an illustration fi^om Cazeaux ), and the toes 
are turned toward the anterior half of the pelvis, the 
back of the fetus is directed toward the leftside: if it be 
the left foot, with the toes similarlj-^ turned, that is, an- 
teriorly, the back of the fetus is toward the right side, 
and vice versa. 

The knees so seldom present, and differ so much from 
the elbow, the only part for which they might be mista- 
ken, that it is not necessary to dwell on their diagnosis. 
They are distinguished by their size, roundness, and the 
magnitude of the members proceeding from them ; to 
which it may be added, that they are less movable, and 
the hams offer concavities instead of convexities, as in 
the bend of the elbows. If any uncertainty is experi- 
enced, it may be removed by bringing down the leg, 
fi'om which no harm would arise should it turn out that 
we had mistaken an arm for the leg, as prolapsion of the 
arm not unfrequently occurs in shoulder presentations, 
without embarrassing any operative procedure that may 
be called for. It may be observed further, that if both 
knees present, we may be sure that they are not elbows, 



336 SPECIAL PHENOMENA OF SECOND STAGE. 



for the child's trunk is never so situated in the uterus 
as to allow both arms to offer at the superior strait. 
The same remark is applicable to the feet; when both 
can be felt, we need not fear that they may prove to be 
the hands, for both hands cannot offer at the same time. 

Prognosis. 

Parturition is ordinarily more tedious and difficult 
in nates than in vertex presentations : the os uteri is 
more slowly dilated, and the process of expulsion is not 
so simple or so vigorously executed. It might, indeed, 
be supposed that the fetus would be expelled more rea- 
dily in nates than in vertex presentations, when the feet 
are foremost, as its small extremity then engages in the 
passages, which are gradually dilated as the base of the 
cone represented by the child's body approaches them. 
What I have put as supposition has been advocated as 
the truth by some writers, who seem to have based this 
opinion upon fallacious analogies, rather than on observa- 
tion or a careful study of the economy of the parturie 
function. 

It is evident that when the small extremity of the 
fetus presents, the most difficult part of the process of 
expulsion is reserved for its closing stage, when the 
shoulders and head have to be transmitted. This would 
offer no difficulty, if the parturient power were more en- 
ergetically exerted then, when there is the most need 
for it. But the fact is otherwise. The uterine fibers, 
like those of aU other muscular structures, lose contrac- 
tile force in proportion as they are shortened by the re- 
duction of the size of the organ, and consequently, 
when the bulky parts of the child remain to be expelled. 



NATES PRESENTATION. 337 



they are incapable of contracting as powerfully as while 
the inferior extremities are passing. The most volumi- 
nous part of the child, and that of which a compliance 
with the mechanical laws of labor is most rigidly ex- 
acted — the head — is to be expelled when the uterine 
power is at its minimum, and is, moreover, baffled by the 
head being partl}^ in the vagina. It is true that, in this 
emergency, the aid of the abdominal muscles is invoked, 
and not more true than fortunate, for otherwise the com- 
pletion of labor would be oftener deferred beyond the 
bounds of safety. 

But even at the commencement of the expulsive 
process, the uterus does not commonly contract so 
efficiently in nates as in head presentations, because, as 
has been already stated, it is drained of its waters soon 
after the rupture of the membranes, on account of its 
orifice not being so well stoppered. In vertex presenta- 
tions, a portion of liquor amnii is nearly always retained 
until after the expulsion of the child; and whether this 
subserves any useful purpose, as has been supposed, by 
moistening the parts, a little of it escaping from time to 
time, it is certain that it sustains the force of the par- 
turient contractions, by keeping up that moderate degree 
of distention of the organ which is most favorable. 

From these considerations, it appears that the advan- 
tages of vertex presentation consist chiefly in the 
surmounting of the greatest difficulties in the early 
stage of labor, when the greatest poAver is possessed and 
exercised by the uterus; viz., procuring the full dilata- 
tion of the OS uteri, and causing the head and shoulders 
to execute, with comparative facihty, the movements 
required of them during their passage, and when these 
22 



338 SPECIAL PHENOMENA OF SECOND STAGE. 



have escapedj the tapering remainder of the child fol- 
lows without difficulty. In this respect, breech presen- 
tations resemble vertex much more than do the feet, for 
the breech, with the thighs folded upon the pelvis, is even 
more voluminous than the head; and therefore, although 
the labor may, upon the whole, be more tedious than in 
feet cases, expulsion is performed with more rapidity and 
facility, because, when the parts are sufficiently dilated 
to allow the breech to pass, they can offer no obstacle 
to the shoulders and head. 

Neither the less energetic manner in which labor is 
executed in nates presentation, compared with vertex, 
nor the circumstances accompanying it, necessarily in- 
volves any increased hazard to the mother. It was for- 
merly believed, indeed, that when the breech presents, 
and the child is necessarily born doubled upon itself, 
that the neck of the womb must be more or less torn, 
or if this accident did not occur, that the woman is very 
liable to have prolapsus uteri. Another difficulty was 
ascribed to such a presentation, viz., that the legs may 
continue crossed upon the breech, instead of being car- 
ried up and extended upon the abdomen. But there 
does not appear to be any foundation for the apprehen- 
sion of serious lesions in these cases, and the legs rarely 
fail to be elevated except where there is room in the 
pelvis to allow them to pass along with the breech. 

The prognosis is much more unfavorable as far as the 
child is concerned, and the risk it runs of being lost 
in the birth, by the cu'cumstances of a nates presenta- 
tion, is so great as to justify us in preparing the father 
at least to expect such a disappointment to his hopes. 
All experience testifies to the truth of this statement; 



NATES PRESENTATIOX. 339 



but it may not be amiss to consult tlie records of the 
Paris x>Iaternity,as collated by Madame Lacbapelle, for in- 
formation as to tbe amount of risks incurred by the 
child. From these it appears that eight hundred and 
four nates presentations pelded one hundred and two 
feelle children, sixteen premature or deformed, one hun- 
dred and fifteen dead, and five hundred and eighty-one 
alive and vigorous. The proportion of deaths to the total 
is one-seventh, while in twenty thousand six hundred 
and ninety-eight vertex positions, only six hundred and 
sixty-eight were dead born, which is not quite one- 
thkty-tirst. It appears, moreover, that the several 
modifications of nates presentation differ in point of fa- 
tahty, the proportion of deaths being about one in eight 
and a half for the breech, one in six and a half for the 
feet, and one in four and a half for the knees. 

The death of the fetus is caused by the compression 
of the umbihcal cord, which, after the breech is expelled, 
is necessarily placed between the trunk first, and subse- 
quently the head, of the child and the pelvis of the mother; 
and if this compression be so great or long continued as 
to intercept the circulation of its blood to and fi'om the 
placenta, it dies asphyxiated, just as a breathing animal 
does from the interruption of its pulmonary cu'culation. 
The less complete dilatation of the os uteri, and the 
consequent more tardy transit of the child, accounts for 
the greater fatality of presentations of the nates where 
the feet are foremost. 



{40 NATES PRESENTATION. 



CHAPTER XYIIL 

TREATMENT OF NATES PRESENTATION. 

There is something in a name, and that of " preter- 
natural " having been affixed to nates presentations, has 
influencedj in no small degree, the conduct of practi- 
tioners in their management of such cases. The father 
of medicine considered nates presentation so unnatural 
that he inculcated, from theoretical considerations, it 
may he presumed, the practice of turning the child in 
order that its head may be made to present- — an opera- 
tion which it is easier to describe than perform : /S'mw^ 
enim facta verbis difficiliora. 

Practical men, finding it difficult, often impossible, 
to execute the orders of the venerable father, fain took 
these presentations as they found them, but convinced 
of their malignity, lent a helping hand to rid their pa- 
tients of them as speedily as possible. It is not long 
since it was the established practice to bring down the 
feet as soon as they could be seized, and extract the 
child by drawing upon its legs. Thus, Mauriceau di- 
rects that where one or both feet present, no other 
cause for interference existing, the accoucheur should 
introduce his hand into the entrance of the uterus, get 
hold of the feet, and bring them out. This is to be 
done as soon as the os uteri is sufficiently dilated, or 
not being dilated, as soon as it can be with the fingers; 



TREATMENT. 341 



and then lie goes on to give directions for the proper 
performance of the operation of extracting the child (1). 
In a subsequent chapter ( XXIII ), treating, among 
others, of breech presentation, he says that when this is 
foremost, if it be small or the pelvis of the mother large, 
it may come forth in this situation, zuith a little assist- 
ance; for though the child has its body doubled, the 
thighs, being flexed upon the belly which is soft, find 
room by its yielding. He hastens to enjoin, notwith- 
standing, that as soon as it is discovered that the breech 
is presenting, the accoucheur must not allow it to ad- 
vance or become engaged in the passage; but he must 
push it up, if this can be done without any violence, 
and passing his hand along the thighs to the legs and 
feet of the child, conduct them one after the other with- 
out the uterus, in a careful manner, to avoid seriously 
twisting or dislocating them, — after which the extrac- 
tion is to be finished as though the feet had come 
foremost. 

An English writer of note, who flourished after 
Mauriceau, Dr. Burton, of York, the cotemporary and 
rival of Smellie, admitted the possibility of the child 
being born with nates presentation, but regarding this 
as " very accidental," he recommends that no reliance 
be placed upon it, but that " as soon as the operator 
perceives, by the softness and fleshiness of the parts, 
what part presents, he must immediately thrust up 
against the buttocks with all his strength, but without 
committing violence to the child's os coccygis, or its 
parts of generation, which are often in this case swelled ; 

(1) Des Maladies des Femmes Grosses, Livre II, Chapter 13. 



842 NATES PRESENTATION. 



and as lie thrusts up, he must endeavor to turn the 
child with its belly toward the os uteri, and then search 
for the feet (1). 

How this tliriiding up tvitli all the operator's 
strength is compatible with a due regard for the child's 
OS coccygis or parts of generation, or, what is of vastly 
more consequence, the mother's parts, we are not told ; 
but it requires no great ken to divine that such barbar- 
ous practice must be productive of the most direful 
consequences. Mauriceau is much more guarded in his 
instructions ; the breech is to be pushed up, if it can 
be done, he says, tuithout any violence ; but he owns 
that it is sometimes so advanced in the passages, that to 
attempt its repulsion would endanger the life of mother 
and child. In such cases, he advises allowing it to 
progress, with such assistance as can be rendered, and 
even makes the following further observation, that 
" there is often less danger in permitting the child to 
advance in this posture than in hastening its extraction 
before the passage is sufficiently prepared and dilated ; 
for the way not being open, and the head of the child 
remaining on this account longer in the passage, after 
the body has been with difficulty delivered, there is 
greater risk of suffocation, than where the parts are dila- 
ted by the breech which has come foremost." 

The practice, indicated by Mauriceau as often advi- 
sable, is that which is now justly deemed nniver sally ap- 
propriate, except it be necessary to interfere on account 
of exhaustion, flooding, convulsions, etc. All are now 
agreed that in nates presentations, whether the breech 

(1) New and Complete System of Midwifery, sect. 88, 1752. 



TREATMENT. 343 



or feet be foremost, the labor should be confided to na- 
ture until the hips are expelled, or the child is born as 
far as to the umbilicus. Concernino; the further man- 
agement, however, there is not the same accord. 
"When the umbihcus is expelled, I say. Nature! you 
have done your work; I must now begin mine — so I 
gTasp the breech with a napkin, and proceed to extract 
carefully, but as fast as I can, working fi-om hip to hip. 
As soon as the body is born, bring down the arms ; 
pass up your finger fi^om the shoulder to the elbow, and 
pressing it toward the chest, bring down the forearm, 
making it sweep over the face; lift up the body of the 
child, and extract the other arm in the same manner; 
the arms being brought down, pass up one or two fin- 
gers on the breast of the child, and introduce them 
into its mouth; press the chin down to the breast; 
with the other hand raise the child toward the pubes of 
the mother, extracting, at the same time, in the direc- 
tion downward and forward ; the delivery will thus be 
readily accomphshed " (1). 

Such is the instruction of the late Dr. Gooch, deliv- 
ered in his usual quaint style. He had just before di- 
rected that, when the feet are protruded, if the toes are 
turned toward the pubes of the mother, a napkin must 
be wrapped around them and as much of the child 
as may be, to enable the accoucheur to lay firm hold 
of them for the purpose of turning the toes to the 
nearest sacro-ihac juncture. This is done to insure 
the turning of the face into the hollow of the sa- 



(1) Practical Compendium of Midvriferj, edited by George 
Skinner, Philadelphia, 1832, p. 209. 



344 NATES PRESENTATION. 



crum, when the head engages in the pelvis. A more 
recent EngUsh writer. Dr. Lee, recommends the same 
practice : " Except supporting the perineum/' says he, 
'^ nothing is required in a great proportion of these cases, 
before the nates and lower extremities have been ex- 
pelled, when it becomes necessary to ascertain precisely 
the relative position of the child to the pelvis ; to rec- 
tify this if it is unfavorable, and artificially extract the 
superior extremities and head, to prevent the fatal com- 
pression of the umbilical cord." It is needless to 
multiply quotations on this point]; suffice it to sa}^, such 
is the general current of British practice, since the time 
of Smellie. It rests, it will be perceived, upon the sup 
position that the natural resources are only adequate to 
the acompKshment, in a safe manner, of less than half 
of the process of childbirth when the nates present. 
>Such a supposition is not supported by observation, 
which teaches indubitably that not only may the child be 
expelled by the unaided contractions of the uterus, but 
that where this takes place, the chances of it being 
born alive are greater, and the risk to the mother is less, 
than where art interposes and pragmatically turns na- 
ture out of doors. Natural delivery^ in all cases^ is pre- 
ferable to artificial, but in none more than in nates pre- 
sentation. Its advantages have been clearly set forth 
by M. Nsegele, in the essay to which reference has been 
so frequently made. They consist, first, in the chin con- 
stantly remaining pressed on the breast during the pas- 
sage of the head through the pelvis, — whict is greatly 
facilitated thereby; secondly, in the arms continuing 
pressed upon the breast, and being born with it; thirdly, 
in the soft passages being dilated so slowly, by the grad- 



TREATMENT. 345 



ual advance of the child, as to opjDose less resistance to 
the head as it follows ; fourthly and lastly, in the con- 
tractile power of the uterus being better sustained, when 
the organ is emptied by its owrn exertions, its walls be- 
ing kept in contact with the child's body. From these 
considerations, it is evident that the manual extraction 
of the child, in nates cases, is much more an artificial 
procedure than delivery by the forceps in vertex presen- 
tations ; and the conclusion is irresistible, that before it is 
undertaken, we ought to be well persuaded of its neces- 
sity. jN^ow, the ground of our interference is the safety 
of the child, and if it be not periled, there is no need of 
our efficient and officious aid. We can, at all times, 
keep ourselves informed as to the state of the child, by 
attending to the pulsation of the cord ; if this be strong 
and regular, it is in no danger, however long its expul- 
sion maybe delayed; if, on the contrary, this be feeble 
and nearly extinct, it is in imminent danger, and its re- 
lease ought to be procured, with as much haste as is 
consistent with a proper regard for the safety of the 
mother. 

Nor is there any necessity for grasping the child's 
inferior extremities or hips, when its abdomen is turned 
toward the anterior parts of the mother, and forcibly 
turning it round to give it a posterior look: such a 
maneuver is not free from danger, as the head may not 
follow the revolution of the body, which then causes fatal 
torsion of the neck ; nor is it at all necessary, because it 
generally executes such a turn spontaneously, or, if ne- 
cessary, this may be insured by the shghtest imaginable 
assistance, simply by drawing gently on the ]eg or hip 
that is anterior, in concert with the pains. 



;46 NATES PRESENTATION. 



Notwithstanding I have deprecated the rendering of 
aid in nates cases, merely on account of the presenta- 
tion, I am thoroughly satisfied that assistance is more 
frequently requisite in these than in vertex cases. 
What we might have expected, reasoning a priori, expe- 
rience has confirmed : the parturient powers not being 
so efficiently exerted, the labor is generally more pro- 
tracted, in all its parts, and may be so long delayed as 
to require the interposition of art, upon the general 
principles that should govern our management of all 
labors. Thus, it is more frequently necessary to pro- 
mote the dilatation of the os uteri, in such manner as 
the circumstances of the case may demand; the breech 
much oftener needs to be helped along than the head ; 
and after its extrication, the superior parts of the body 
oftener require to be assisted in their passage than do 
the inferior parts, after the head is extricated in vertex 
cases : and all this may be demanded, not less for the 
mother's than the child's safety. This accords with the 
experience of Madame Lachapelle, who states that to 
give aid, in coincidence with the natural efforts, is almost 
a general indication to be fulfilled in these cases. Let 
it be observed, too, that the aid we are contemplating 
must be strictly in subordination to the natural efforts ; 
we must be content to follow, without aspiring to lead, 
nature. 

Should it become necessary to promote delivery, 
then, nothing 'having occurred to justify us in forcing 
it or making it essentially artificial, it can never be 
proper to bring down the feet where the breech is the 
presenting part ; but we must limit ourselves to the use 
of such extractive force in aid of the pains, and always 



TREATMENT. 347 



in concert witli tliem, as can be safely employed. Two 
fingers, passed over the groin of the child, can make as 
powerful traction as is commonly necessary, and this 
method of assisting is preferable to the blunt hook, 
which is apt to inflict serious injury upon the child, and 
may fracture the thigh. The mechanism of labor points 
out the proper mode of operating with the fingers ; it 
consists in closely following the steps of nature. If the 
breech has not entirely traversed the superior strait, so 
as to occupy the pelvic cavity completely, the fingers 
should act upon the groin that is anterior, or alternately 
upon it and that which is posterior, but chiefly upon 
the former, because in so doing, traction is made in the 
direction of the axis of the superior strait. But when 
the inferior strait only remains to be cleared, traction 
must be made upon the groin that is posterior, in crder 
that the force which is exerted may be in the direction 
of the axis of the inferior strait. After the hips are 
born, they should be embraced by the hands in such a 
manner that the thumbs may rest upon the lower part 
of the spine, and be alternately raised and depressed, 
as the tractive efforts are continued, which is expressed 
by the phrase, tvorking from hip to hip. When the 
umbilicus is liberated, a loop of the cord must be 
brought down to free it from injurious extension, and, if 
the arms are carried up alongside the head, they must 
be brought down separately, commencing with that^ 
which is situated posteriorly, by passing two fingers 
along the humerus, as near to the elbow as possible, and 
depressing them over the face and breast of the child -, 
and, finally, when the head is brought into the excava- 
tion, the right hand is to be introduced along the 



148 NATES PRESENTATION. 



sacrum, and two fingers passed into the mouth, to flex 
the head by depressing the lower jaw, while the left 
hand makes tractions upon the shoulders of the child. 
The body of the child, resting upon the right arm of the 
accoucheur, is to be considerably elevated toward the 
mother's abdomen, while the head is being extracted by 
the hands, placed as already indicated. 

It has been already stated that it is not unfre- 
quently necessary to assist, in the manner thus briefly 
described, in cases of nates presentation; and that our 
assistance should cooperate with the laborpains. If we 
are careful to abstain from making tractions in the inter- 
vals of the pains, the delivery, though assisted, may be 
perfectly natural, that is, the arms may remain crossed 
on the breast, and the fundus of the uterus pursuing 
the child, may keep its head well flexed, so that but 
httle force need be exerted by us; and when the child 
is born, the womb may be firmly contracted, and the 
woman in no more danger of accidents of any kind than 
after the most ordinary delivery. It is very different 
when nature is unceremoniously set aside, as recom- 
mended by Gooch and others; then the delivery is ne- 
cessarily unnatural: — tractions made in the absence of 
pain, draw down the body, while the arms maintain their 
position, and come to be placed alongside the head, or 
the body being twisted around to throw the face toward 
the sacrum, the arms are placed behind the occiput ; 
and when the head is pulled into the pelvis, it becomes 
extended, and must be reflexed before it can pass 
through: but above afl, there may be an increasing 
vacuity of the uterus, as the withdrawal of the child is 



TREATMENT. 349 



going on, and the organ may be left in a flaccid condi- 
tion after delivery. 

But although I have condemned artificial delivery, 
in anticipation of danger to the child, I have admitted 
that it is proper when danger actually threatens it, as 
we are warned by the languishing state of the umbilical 
circulation. It must be allowed, moreover, that there is 
not any valid objection to hastening the exit of the 
head in all cases, if it be much delayed, because it is 
but partially contained in the uterus, and if the labor 
have been natural thus far, there is but small risk of 
any evil consequences to the mother. The extrication 
of the head may be greatly aided by the voluntary ef- 
forts of the patient, even more than by the uterine con- 
tractions; she should, therefore, be reminded to bear 
down or strain, and such an effort is often alone suffi- 
cient, if the disposition of the head is favorable to its 
egress. If, in spite of the united efforts of the patient 
and practitioner, the child be endangered by the long 
retention of the head, it may be succored for a consid- 
erable time, by raising its body, and passing the hand 
along the sacrum above the mouth, and pressing back 
the perineum so as to enable it to breathe. M. Gardien 
avers that he has often witnessed the success of this 
precaution, in estabhshing respkation and saving the 
child, notwithstanding such compression of the cord as 
would otherwise have been fatal to it (1). Other au- 
thors, among them Dr. Meigs (2), testify to the same 

(1) Traite Complet d'Accouchemens, Tom. II, p. 328. 

(2) Philadelphia Practice of Midwifery. 



;50 NATES PRESENTATION. 



effect: I cannot, therefore; think it judicious or proper 
to adopt the counsel of the last-named gentleman, to 
send for our forceps whenever we discover that the 
nates are presenting, that we may be prepared to ex- 
tract the head instrumentally as promptly as he recom- 
mends ; for, although it may not be difficult to use the 
forceps in such a case, instruments ought not to be re- 
sorted to under any ckcumstances where the hand may 
supersede them, as I believe it always may, in the case 
under consideration, provided it be properly employed, 
that is, provided the entire hand, and not merely two 
fingers, as commonly directed, be introduced over the 
chin. 

If the child may be withdrawn with greater precipi- 
tancy than is altogether consistent with what is safest 
for the mother, when its life is in peril, much more may 
we extract it by such means as are not safest for it, 
when this is demanded by the condition of the mother. 
If the labor be, therefore, so protracted as to end in ex- 
haustion, or if convulsions or any other threatning acci- 
dents supervene, in nates cases, we shall be justifiable 
in resorting to instruments, provided manual assistance 
be not sufficient. For the purpose of extracting the 
breech, the blunt hook is commonly preferred, but I am 
not sure that it is safer for the child than the forceps. 
Against the latter it is objected that the extremities of 
the blades may rest on the abdomen and contuse its 
viscera. But such a consequence is not necessary or in- 
evitable, and we know that the blunt hook has terribly 
contused the groin and fractured the thigh bone, accord- 
ing to the candid admission of its advocates. The most 



TREATMENT. 351 



that can be said in favor of the blunt hook is, perhaps, 
that it is safer for the mother; and if a practitioner is 
persuaded that he can use it with the least risk to her, 
it is his duty, when he is acting for her benefit, to 
prefer it. 



352 SPECIAL PHENOMENA OF SECOND STAGE. 



CHAPTEU XIX. 

FACE PRESENTATION — ITS MECHANISM, DIAGNO- 
SIS, AND PROGNOSIS. 

Before describing their mechanism, it is necessary to 
observe that face presentations may be primitive or se- 
condary — that is, the head may be completely retro- 
verted, causing the face to offer fully at the superior 
strait, when labor begins j or it may be only partially 
retroverted, in which case, the anterior fontanel is found 
presenting at first, but in the progress of labor, this is 
replaced by the face. Secondary face presentations are 
considered by authors as deviations from those of the 
vertex, produced by obliquity of the uterus; but differ- 
ent explanations have been given of the modus oper- 
andi of this alleged cause. Baudelocque maintained 
that it is the manner in which the uterine force acts 
upon the head, where obliquity exists, that causes it to be 
extended rather than flexed, and thus gradually brings 
the face into the pelvis in place of the vertex. The ob- 
liquity, he affirms, is almost always toward the side 
where the occiput is placed, and the force of the uterine 
contractions traverses the head obliquely from its base 
to the vertex and .'rom the occiput to the forehead, a 
little anterior to its center of motion, and terminates 
upon the forehead, which it tends to depress ; but to 



FACE PRESENTATION. 353 



depress the forehead is necessarily to raise the occiput, 
or, in other words, to extend the head. 

Dugas accounts, more satisfactorily, I think, for the 
transformation of vertex into face presentations, by at- 
tributing it to the impulsion of the occiput against the 
side of the superior strait, where it is of course arrested, 
and the face is made to descend by the head represent- 
ing a lever of the thkd kind, the prop being at the oc- 
ciput, the resistance at the forehead, and the power at the 
occipito-atlantoid articulation. 

Secondary face positions, being nothing more than 
transmutations of vertex presentations, are apt to re- 
tain a part of the character of their original, viz., they 
are usually diagonal instead of dkect, the chin being di- 
rected toward one of the sacro-ihac symphyses, and be- 
cause the first vertex position is most common, the first 
facial position is so likewise, seeing that a considerable 
number of face presentations are secondary. 

It will be remembered that we admit but two posi- 
tions of the face, namely, the left fronto-iliac^ and the 
right fronto-iliac. In the first, the forehead corres- 
ponds to the left niac fossa, and the chin to the right, 
the front o-mental diameter is parallel with the trans- 
verse diameter of the pelvis, and the bimalar diameter 
is parallel with the sacro-pubic ; the back of the child 
looks toward the left side of the mother, and its breast 
toward the right ; its right side is forward, and its left 
backward. In the second, the relations of ih^ fetus 
to the mother are the reverse of the first, but the same 
diameters of the head correspond to the same diameters 
of the pelvis. 

It is hardly necessary to describe the mechanism of 
23 



354 SPECIAL PHExVOMENA OF SECOND STAGE. 



expulsion in the two positions of the face separately, so 
neai-ly do they resemble each other. They will, there- 
fore, be considered in connection, and what is peculiar to 
each pointed out in its proper place. 

The mechanism of face presentations comprises 
the following movements: 

Fij-st step — descent of the face. — If the head be 
so completely extended as to ofier the face fully to the 
superior strait, as it is in the primitive cases, no resist- 
ance is made to its engaging in it, for its small diame- 
ters, the gutturo-bregmatic and bimalar, apply for ad- 
mittance. In such instances, descent of the face to the 
bottom of the pelvis is the whole of the first step. But 
in secondary positions, gradual extension of the head, by 
which the forehead is depressed and moved from one 
side of the pelvis to the other, takes place preparatory 
to the engagement of the face, which then descends as 
in primitive positions. In secondary cases, it is the 
occipito-frontal diameter of the head which is first par- 
allel with the transverse or obhque diameter of the su- 
perior strait; in the progress of their transformation, 
this cephalic diameter is replaced by the occipito-mental, 
which is eventually succeeded by the fronto-mental. 
In both primitive and secondary positions, it is the gut- 
turo-bregmatic diameter which traverses the pelvis 
transversely or diagonally. 

Second step- — rotation. — The face now rotates, and 
the chin revolves forward, from the right in the first 
position, from the left, in the second position, and is 
lodged under the symphysis pubis; while the vertex is 
thrown into the hollow of the sacrum, and the forehead 



FACE PRESENTATION. 355 



rests on the floor of the pelvis posteriorly. This rota- 
tion is to the extent of one-fourth of a circle in primitive, 
three-eighths of a circle in secondary, positions, and 
when it is achieved, the guttnro-bregmatic diameter is 
parallel with the coccy-pubic. 

Third step — flexion. — The head next begins to 
be flexed, which causes the chin to emerge first from 
under the symphysis pubis and rise toward the mens 
veneris, until its further movement is checked by the 
anterior part of the neck being pressed against the pos- 
terior surface of the symphysis. The action of the ex- 
pulsive force upon the chin being destroyed by this re- 
sistance, but continuing to bear upon the other extremity 
of the occipito-mental diameter, the occiput is made to 
descend until the head is completely disengaged under 
this flexion movement. While it is being executed, the 
head, as M. Cazeaux observes, represents a lever of the 
third kind, whose prop is at the guttural fossa, resting 
on the under edge of the symphysis pubis, the power 
being at the occipital foramen, and the resistance at the 
occiput: and the gutturo-frontal and other coincident 
diameters measure the antero-posterior diameter of the 
inferior strait, as the forehead, bregma, and occiput suc- 
cessively emerge before the anterior border of the 
perineum. 

Fourth step, — The face turns toward the side to 
which the chin corresponded at the beginning of labor; 
the shoulders and rest of the trunk engage and are de- 
livered as in vertex presentations. 



356 SPECIAL PHENOMENA OF SECOND STAGE. 



Remarks. 

The mechanism of face positions is hable to several 
anomahes, two of which deserve especial notice. 

First, Rotation may take place before the face has 
completely descended in the pelvis. To understand the 
reason of this, it is necessary to observe, that the 
length of the child's neck is not sufficient to allow 
the face, in any case, to reach the inferior stiait in a 
transverse position, so as to have the chin upon a level 
with one ischiatic tuber and the forehead upon a level 
with the other, for the depth of the lateral walls of the 
pelvis exceed the length of the neck. In order, there- 
fore, that the face may complete its descent regularly, 
flexion must take place in a slight degree, that is, the chin 
remaining as low as the neck will permit, the forehead 
must be pushed down to the floor of the pelvis. This in- 
ternal flexion, which accompanies descent, was not no- 
ticed in describing the mechanism, for fear of confusing 
by complicating its study. Now, instead of thus flex- 
ing to reach the inferior strait, the head may rotate 
the chin forward, behind the symphysis pubis, and then 
the anterior part of the neck being opposite the short or 
pubic wall of the pelvis, there is no obstacle to the speedy 
completion of its descent. When the face traverses the 
pelvis in this manner, there is first descent, as far as the 
neck will allow, then rotation, and finally descent resumed 
and completed. These anomalous movements, as I regard 
them, are described by M. Cazeaux as the regular march 
of nature, in face presentation, although he admits that 
in a large number of cases, what I have described as the 
ordinary mechanism, does really occur, that is, partial 



FACE PRESENTATION. 357 



flexion and complete descent of the face, prior to 
rotation. 

Second, The head may rotate so as to throiv the chin 
into the holloiv of the sacrum, or the chin, heing directed 
toivard one of the sacro-iliac symjohyses from the begin- 
ning, may retain its posterior look from defaidt of 
rotation. 

If there have been no interference with the regular 
progress of the labor, it is exceedingly rare that rota- 
tion fails to carry the chin forward and place it under 
the symphysis pubis. This occurs in the diagonal posi- 
tion of the face, where the chin is opposite one of the 
sacro-iliac symphyses, with even greater uniformity, than 
does the revolving of the occiput forward in posterior 
positions of the vertex. The testimony of M. Nsegele 
to this effect, is very decided : " In a midwifery prac- 
tice of twenty years," says he, "I have never had a case 
come before me, where, in presentation of the face as the 
labor advanced (if no mechanical assistance had been 
given by art, as for instptuce, changing the direction of 
the head, bringing it down further, etc. ), the forehead 
had turned itself forward or upward, and brought the 
face at the inferior aperture of the pelvis, into a direc- 
tion contrary to the usual one. I have been assured of 
this by several accoucheurs, who were men of observation, 
some of whom had been much longer in practice than 
myself" (1). 

Madame Lachapelle, speaking of the second step of 
the mechanism of face position (rotation), declares that 
it is constant and constantly the same. She says, indeed, 

(1) Mechanism of Parturition, p. 81. 



358 SPECIAL PHENOMENA OF SECOND STAGE. 



that she has, two or three times, seen the face escape at 
the Yiilva transversely, or nearly so ; but these she reckons 
rare exceptions, and thinks it may be laid down as a 
general principle, that, in all manner of face presenta- 
tions, rotation is effected in the excavation, so as to bring 
the chin under the pubes, while the vertex is lodged 
in the hollow of the sacrum ( 1 ). 

It cannot be doubted, nevertheless, that the chin 
does occasionally remain opposite the sacro-iliac sym- 
physis, or turn into the hollow of the sacrum, an instance 
of each of which is related by Dr. SmeUie, whose accu- 
racy may not be questioned (2). In such instances, in 
order that the face might escape through the inferior 
aperture of the pelvis, it would seem that additional and 
extreme extension of the head must take place; and so 
it must, could the head be expelled by a mechanism 
analogous to that of occipito-posterior positions of the 
vertex. This is, however, physically impossible, where 
the child is fully developed, as Madame Lachapelle has 
irrefutably demonstrated. It is impossible, because 
either the sternum and clavicles must abide at the sacro- 
vertebral angle until the chin passes out before the peri- 
neum, which would require the neck to be so enormously 
stretched as to measure the whole length of the sacrum, 
coccyx and perineum (at least eight inches) , — or the 
thorax must be drawn into the excavation between the 
head and sacrum, and be so flattened as to occupy not 
more than two inches of the antero-posterior diameter 
of the excavation, leaving three inches for. the cervico- 



(1) Pratique des Accouchemens, Troisieme Memoire. 

(2) Collection XXX, Cases IV and Y. 



FACE PRESENTATION. 359 



bregmatic diameter of the head. The head cannot, 
therefore, be expelled by the natural efibrts, or extracted 
by art, in such cases, unless the position be first changed 
to one more favorable, or transmuted into a vertex posi- 
tion. When transmutation is effected, it is produced 
either by the gradual depression of the occiput, the chin 
being stayed against the pelvic wall, and becoming the 
center about which the occipito-mental diameter describes 
a considerable arc of a circle, or by the chin mounting 
upward, as the occiput is forced downward. In either 
way the occiput subsides behind the pubes, and, appear- 
ing at the superior part of the vulva, emerges first: the 
rest of the head is expelled as in vertex positions. 
Professor Meigs gives a different account of the head's 
passage through the inferior strait: after having de- 
scribed the mechanism of the mento-anterior position of 
the face, he says, " A very contrary state of things fi'om 
the foregoing obtains, where the chin, instead of revoi- 
Ymg toward the fi:ont, turns toward the back part of 
the pelvis. Here the forehead must be born first; then 
the nose ; the mouth ; the chin escapes from the edge 
of the perineum, and then retreats toward the point of 
the coccyx, allowing the crown of the head to pass out 
under the arch ; and, lastly, the vertex emerges, which 
concludes the delivery of the head " (1). Professor 
Meigs does not inform us whether the picture he has 
drawn is taken from nature, and none of the cases he 
relates is the counterpart of it. These mento-posterior 
positions, moreover, are, as has been already stated, 
very rare, and still rarer is spontaneous defivery in 



(1) Philadelpliia Practice of Midwifery, first edition, p. 203. 



360 SPECIAL PHENOMENA OF SECOND STAGE. 



them; it may, therefore, be presumed that he has copied 
from some other artist, but I know not from whom. 
Smelhe, the only author to whose cases Professor Meigs 
refers, states expressly that, in the case (No. 5) where 
he found it necessary to deliver with the forceps without 
changing the position, " the parts between the coccyx 
and OS externum were gradually extended by the 
face and forehead of the child, and at last yielded, so as 
to alloiv the vertex to come out from lelotu the pubis ; 
then turning the handles of the forceps toward that 
bone, I delivered the woman safely of a dead child, 
which AY as, in all probabihty, lost by the long compres- 
sion of its head in the pelvis." Any one who has ever 
dehvered with the instrument, will readily allow that 
this description is much more suitable to forceps deliv- 
ery in vertex than in ordinary face cases. 

Diagnosis. 
It is not difficult to recognize the face under circum- 
stances favorable to an examination, viz., when the part 
is sufficiently within reach of the finger, the os uteri 
dilated, the membranes flaccid, in the intervals of the 
pains, or, better still, ruptured, provided too long a time 
has not elapsed since their rupture. We can then dis- 
tinguish, on one side of the pelvis, the forehead, by its 
round, smooth, and solid surface, marked by the com- 
missure which divides it; extending our researches to- 
ward the other side of the pelvis, we feel the triangular 
projection made by the nose, and may even feel both 
nostrils by pressing the finger against them — then the 
transverse fissure of the mouth, with the lips and gums, 
and finally the chin. On either side of the nose and 



FACE PRESENTATION. 361 



mouth, the cheeks may be distinguished, feeling hke 
soft tumors, surrounded with a bony circle; the cheek 
that is anterior ( the right in the first position, left in 
the second position) may be most easily reached. 

Bat under less favorable circumstances, especially 
when a long time has elapsed since the escape of the 
waters, and the face is greatly swollen fi^om infiltration 
of its loose, cellular tissue, it may not be easy to penetrate 
its disguise. The tumid cheeks, pressed together, con- 
vert the median line of the face into a deep furrow, in 
which the distinctive characters of the face lie buried; 
and this fiirrow may be mistaken for the cleft of the na- 
tes, for which the distended cheeks palm themselves. 
When to this it is added that the lips are swollen, in- 
verted, and puckered, so as to offer a round orifice in- 
stead of a transverse sht, which might pass for the anus, 
it ought not to be matter of surprise if a jury of ma- 
trons, sitting cheek hy jotul, should mistake the face for 
the breech. More astute judges have acknowledged 
that they have been thus deceived, and he who laughs 
at them, shows that either he has had but little experi- 
ence, and is therefore impregnable in his practical igno- 
rance, or he is uncandid and uncharitable. 

The remarks, which have now been made, relate to 
primitive, or at least to full, presentations of the face; 
the secondary positions are to be distinguished by the 
anterior fontanel, the superior portion of the orbits of 
the eyes, and the root of the nose. As the labor pro- 
gresses, the fontanel recedes, the eyes, nose, and mouth 
approach, and finally the chin can be felt. 

The presentation being ascertained, there is no diffi- 
culty in making out the position — the chin is toward 



362 SPECIAL PHENOMENA OF SECOND STAGE. 



the right nium in the first, toward the left ihum in the 
second position. 

Prognosis. 

Although presentations of the face were, for a long 
time, regarded as essentially preternatural, it may be 
easily demonstrated that they do not necessarily offer 
any obstacle to parturition, which the natural resources 
cannot surmount, nay, that, so far as the passage of the 
head merely is concerned, there is no material difference 
between them and vertex presentations. The diameters 
which the face applies to the superior aperture of the 
pelvis, viz., the fronto-mental and bimalar, do not exceed 
those which the vertex applies, viz., the occipito-frontal 
and biparietal, while the face is traversing the excava- 
tion, it offers the guttero-bregmatic and bimalar diame- 
ters, which again are not greater than those with which 
the vertex progresses, viz., the cervico-bregmatic and 
biparietal ; and, lastly, when the face is about to clear 
the inferior strait, it is still the guttero-bregmatic diam- 
eter which it offers to the coccy-pubic diameter, and 
this is as good a passport as the cervico-bregmatic, 
offered by the vertex. In short, in face presentations 
as well as in vertex, the axis of the head is nearly par- 
allel with the axis of the strait it is traversing, and 
hence the essential condition, explained in treating of 
vertex positions, is fulfilled in both cases, — the princi- 
pal difference between them being that, in face cases, 
the mental extremity of this axis is downward, while in 
vertex positions, the occipital extremity is downward. 

What has been advanced in the preceding paragraph 
is true only of primitive positions of the face, for it is 



FACE PRESENTATION. 363 



evident that in secondary positions, the head is not so 
favorably situated in relation to the pelvis : the forehead 
being at the center of the superior strait, its axis, so far 
from corresponding with the axis of the strait, is placed 
parallel with the transverse or oblique diameter of the 
strait ; and as its axis is the greatest dimension of the 
head, it is not possible for it to engage in the pelvis 
without additional extension, which is, as has been 
shown, a part of the first step of the mechanism in such 
cases. Under such circumstances, what has been erro- 
neously affirmed of all facial presentations may be truly 
said, — parturition cannot be accomplished unless the 
head be small, or the pelvis large, until the face fully 
present. The disadvantages of secondary positions, in 
this respect, are so great that it is matter of astonish- 
ment that so able and accomplished a writer as M. Gar- 
dien should not only deny the fact, but assert the con- 
trary to be true ; for he says, " We are surprised that 
some authors have thought that labors in which the 
child presents the forehead are more unfavorable than 
where the face is the presenting part. It is evident 
that the difficulties in the way of delivery are greater 
when the face presents, since the diameter which must 
traverse the superior strait is longer than where the su- 
perior part of the forehead presents " (1). In either 
case, however, in M. Gardien's opinion, there is so great 
a want of conformity between the dimensions of the 
head and those of the pelvis, that its rotation and disen- 
gagement are prohibited, unless the head be very small 
and the pelvis very spacious (a moins que le bassin ne 

(1) Traite complet d'Accoucliemens, Tom. II, p. 309. 



364 SPECIAL PHENOMENA OF SECOND STAGE. 



soit tres specieux et la tete tres-petites), thus estima- 
ting, at a very high rate, the diiificulties attendant upon 
any kind of face presentation. 

Madame Lachapelle labored to show, by reasoning 
and observation, the falsity of such an exaggerated esti- 
mate of these presentations, and contributed, more than 
any other writer, to place them in their true hght before 
the profession. Adopting Levret's comparison of the 
head to a cone, of which the occiput is the apex and the 
face the base, she declares that as the head lies in the 
excavation after being extended or flexed, according as 
the face or the vertex presents, the only difference is that 
in the one case, the base of the cone is above, and in the 
other it is below ; and then she inquires, what matters 
it, whether the base or the apex is in advance, inasmuch 
as in both cases alike the cone moves in the direction of 
its axis or greatest length ? Must not the diameters 
and circumferences be always the same? 

In her zeal to overthrow established opinions and 
prejudices, as it appears to me, Madame Lachapelle goes 
too far when she declares that face presentations are 
more favorable to delivery than vertex ; this opinion 
rests, in good part, on the assertion that, as there is 
more free space between the chin and the spine than be- 
tween the occiput and spine, the chin may^ more com- 
pletely emerge from under the pubis than the occiput 
may, and consequently less of the base of the cone has 
to pass out at once. She allows, nevertheless, that the 
r(?«/ advantage thus gained is diminished by the breadth 
of the jaw, which hinders it from occupying the arch so 
fully as does the occiput. 

Now, although I have stated that, so far as the pas- 



FACE PRESENTATION. 365 



sage of the head is concerned, there is no material dif- 
ference between face and vertex presentations ; yet it 
must, I think, in candor be admitted, that there is some 
difference. The face may unquestionably engage in the 
pelvis as readily as the vertex, nor is there any reason 
to believe that it may not descend as readily until its 
free progress is arrested by the shortnesss of the neck ; 
afterward, as it can continue to advance only by becom- 
ing flexed, unless it rotate, the head's axis is made to 
decline from the axis of the pelvis, as th^ chin moves 
toward, and is pressed against, the pelvic parietes, and 
consequently greater diameters of the head are brought 
into the pelvis, which must impede the completion of 
its descent, if it be large, or the pelvis contracted, or 
the soft parts resistive. 

But even though there were absolutely no difference 
between face and vertex presentations, in regard to the 
magnitude of the diameters they offer, the former la- 
bor under a disability from Avhich the latter are exempt 
viz., the circuitous manner in which the force of the 
uterine contractions is transmitted to the head, and the 
consequent loss of power. This will be readily compre- 
hended, when it is remembered that the face can only 
be made to present by the yielding of the ligaments 
and fibro-cartilages of all the cervical vertebrae, in con- 
sequence of which the neck is bent backward like a 
bow, and that the head is moved by the uterine force, 
transmitted through the spine. The force, therefore, in- 
stead of operating in a direct line, reaches the head 
nearly at right angles, after traversing the bend of the 
neck, and loses considerably on account of the indirect 
manner in which it is exerted. This disability is felt in 



366 SPECIAL PHENOMENA OF SECOND STAGE. 



every step of the mechanisnij but especially in the third 
( flexion ), when, as we have seen, the head represents, 
in both face and vertex cases, a lever of the third kind, 
which necessarily involves a loss of power, or in other 
words, the working of which requires the employment 
of much power. If, on this account, the extension of 
the head in vertex cases may fail to take place for want 
of adequate uterine force, we should, a fortiori^ expect 
that in face cases, its correspondent movement, flexion, 
may fail, and require extraordinary aid for its achieve- 
ment. M. Cazeaux reports a case of face presentation, 
in which an attempt was unsuccessfully made to deliver 
with the forceps, but the child was expelled naturally, 
ten hours after the rupture of the membranes \ in care- 
fully examining it, he could feel, in the vicinity of the 
posterior fontanel, something like little sphnters of bone, 
which crepitated under the finger, and a marked de- 
pression was observable upon the dorsal region, — from 
which he infers, I think justly, that the thorax was 
flexed upon itself, and strongly pushed against the 
superior part of the occiput, to aid in urging it for- 
ward (1). 

From the foregoing remarks, it may be concluded, 
that labors, in which the face presents, are not necessa- 
rily much more difficult than vertex presentations, but 
at the same time they are liable to be more protracted, 
and to involve more suffering, if not more hazard, as 
far as the mother is concerned. With regard to the 
child, the prognosis is different; it is more apt to be 

(1) Traits Theorique et Pratique de I'Art des Accouchemens, 
p. 342, note. 



FACE PRESENTATION. 367 



stillborn, and runs decidedly more risk of being lost in 
the bii'th. These elFects result from the compression 
unavoidably experienced by the extended neck, which, 
arresting the return of blood from the head, produces 
cerebral congestion and a disposition to convulsions. 
The stasis of blood adds to the swelhng of the face, 
which takes place independently of it^ from the sero- 
sanguineous infiltration which any part that presents is 
liable to, for the reason assigned when treating of ver- 
tex positions ; and hence the visage, fi-om its tumefac- 
tion, turgescence, and hvidity, may be frightful to be- 
hold, even where the child is born alive or is easily 
resuscitated. But under the use of the usual discu- 
tient applications, this hideous mask, as Madame La- 
chapelle calls it, is thrown off in a few days, and the 
•countenance regains its healthy tint and expression. 



368 FACE PRESENTATION. 



CHAPTER XX. 

TREATMENT OF FACE PRESENTATION. 

While face presentations were regarded as essentially 
bad or preternatural, they were supposed to require the 
effective interference of art, for the safety of both mother 
and child. Thus Baudelocque, who entertained such an 
estimate of their character, enjoins, as a general indica- 
tion, the redressing of the head, by pushing up the face 
or pulling down the occiput, to cause the vertex to pre- 
sent; or, when we cannot thus happily second the 
efforts of nature, either because we are called too late, 
or there is pressing occasion to deliver immediately, the 
turning of the child, and bringing it by the feet, or ex- 
tracting it with instruments, when it is deeply and closely 
engaged in the pelvis (1). Baudelocque was, however, 
fully aware that the head may be spontaneously trans- 
mitted in face positions, and he describes, accurately, their 
mechanism ; but it must be considered a striking proof of 
the baneful influence of prejudice, that notwithstanding 
this knowledge, and the further observation made by 
him, that the labor in these cases is sometimes finished 
with "astonishing facility," he continued to adhere to 

( 1 ) Par. 1347. 



TREATMENT. 369 



the general indication above enunciated. Why was M. 
Baudelocque astonished at the occasional facility of par- 
turition in face presentations, — but because he had pre- 
judicated that they must be difficult? 

Some animadversions upon the several items, em- 
braced in this general indication, may assist us in set- 
tling our duty in the management of the cases under 
consideration. 

And first, {a) The redressing of the head when the face 
is fully presenting, — With regard to the method of ful- 
jBilling this indication, it may be observed, that most 
authors, before the time of Baudelocque, directed several 
fingers to be applied to the chin, root of the nose, or 
cheeks of the child, for the purpose of simply pushing 
up the face, in order that the occiput may descend. But 
Baudelocque preferred acting upon the occiput, and 
bringing it to the center of the pelvis, by curving 
the fingers and advancing them over the surface of 
this part of the head, even as far as to the nape of the 
neck. The lever is, also, recommended for the same 
purpose. Baudelocque's experience authorized him to 
declare, that this maneuver may be executed without 
much difficulty, ivhen the head is still free at the en- 
trance of the pelvis^ or susceptible of leing easily re- 
turned thither; and other experience, that might be cited, 
corroborates his. But when these favoring conditions 
exist, we should not now feel at hberty to redress the 
head, as we do not beheve that it is laboring under any 
grievous wrong. Face presentations are brought, by the 
unaided efforts of nature, to a satisfactory issue, so con- 
stantly, as regards the mother, and in so large a propor- 
tion of cases, as regards the child, that we should not, 
24 



370 FACE PRESENTATION. 



in anticipation of difficulty, be justifiable in causing 
the mother to experience the suffering and incur the 
risk of the operation, however slight that may be 
considered. 

When the face has become fully engaged in the pel- 
vis and is so closely confined there, either by its own 
magnitude or the strength of the tonic contraction of 
the uterus, that it cannot be easily pushed up above the 
brim of the pelvis, the redressing of the head ought, in 
my judgment, be considered as out of the question. 
Baudelocque admits that it is always difficult, often im- 
practicable. Why, then, attempt the operation under 
such circumstances, with the prospect of failure and the 
serious risk of injury to the mother ? If the face be 
without the os uteri, or even if it be within it, but firmly 
grasped by the cervix, this pi^liing up is fi:a,ught with 
danger, for it may lacerate the cervix, or rend its connec- 
tions with the vagina. Yet, it is evident, the head must 
be lifted out of the pelvis, preparatory to its rectifica- 
tion, because it will be impossible to seesaw the axis of 
the head in the pelvic excavation, — its dimension, to 
say nothing of the thickness of the fingers interposed 
between it and the pelvis, being too great to allow such 
a movement. Should labor, therefore, be arrested in 
this stage of its progress, or any symptoms be devel- 
oped, making it necessary to deliver, some other method 
must be had recourse to. 

(J) When the face only partially presents. — This 
will be readily recognized as our secondary face position, 
that is, vertex presentation in process of conversion into 
a facial. If its conversion is arrested or retarded by 
any cause whatever, whether on account of rigidity of 



TREATMENT. 371 



the neck, or inefficacious contraction of the uterus, it 
may prove a serious or insurmountable obstacle to deliv- 
ery, for the longest diameter or axis of the head tends 
to engage in the pelvis. In this case, Baudelocque ad- 
vises us to sustain the forehead, with several fingers 
pressed against it, during every pain, in order that the 
natural efforts may act on the occiput and cause it to 
descend, cautioning us to beware of pressing on the an- 
terior fontanel and vicinity, for fear of inflicting fatal 
injury on the child, by depressing the bones, which are 
here very thin and flexible. By this simple procedure, 
he represents it as an easy task to prevent the head 
from assuming such a vicious position as it engages in 
the pelvis. Should the head have taken up this vicious 
position, it is stifl by the same method, that he proceeds 
to redress it and restore it to its natural march; and if 
this alone prove ineffectual, he introduces the index and 
middle fingers of his other hand above the occipital pro- 
tuberance, to cause it to descend, by drawing toward 
himself as though he were using a crotchet. 

Dr. Dewees treats of this case, in a very instructive 
manner, under the style of the " chin departing too early 
from the breast." He considers it as it is observed at 
two different periods of labor, ^' first, where the head has 
not descended entkely mto the lower strait; and second, 
where it occupies the low^er strait." In the first situa- 
tion^ he recommends acting upon the forehead with the 
fingers, after the manner of Baudelocque ; but in the 
second, more especiaUy if the head have escaped through 
the orifice of the uterus, he thinks it essential to success 
to employ the hand to raise the whole head, " that we 
may be certain of keeping the forehead sufficiently high 



372 FACE PRESENTATION. 



to permit the vertex to descend ;" and then the fingers 
are to be applied to the forehead, as in the first situa- 
tion. A case related by him shows, in a very striking 
light, the value of a correct knowledge of the mechan- 
ism of this case, and of sound principles in obstetric 
practice. I beg leave to commend the case to the 
reader's careful perusal, but at the same time to ques- 
tion the necessity or safety, in less dextrous hands at 
least, of the particular manipulation practiced by Dr. 
Dewees. As to the safety, I have already expressed 
my aversion to raising a head escaped from the uterus; 
and the necessity of it, in this particular instance, is not 
very apparent, for the forehead can be raised or the oc- 
ciput drawn toward the aperture of the pelvis, if it may 
not be brought any lower, and the malposition be thus 
rectified without preliminary elevation of the head. If 
the face, presenting fully, have become closely engaged 
in the pelvis, and it were deemed proper to redress it, 
it must, we have seen, be raised above its brim as a 
necessary preparation, because the axis of the head can- 
not be seesawed in the excavation; but not so, in the 
partial facial presentation, — because although the head 
engages with its axis lying across and above the pelvic 
entrance, the axis itself, or the longest diameter of the 
head, does not become actually engaged ; or if it does, 
there is no reason why it may not retreat as well as 
advance. 

Madame Lachapelle declares, as the result of her 
experience, that the forehead cannot be hindered from 
descending, or be restored after it has lapsed, by the 
mere pressure of the fingers against it, — such puny op- 
position being altogether insufficient to resist the com- 



TREATMENT. 373 



bined effort of the uterus and abdominal muscles. She 
ad\ises us, therefore, to promote rather the descent of 
the face, as it is easier to reach and act upon the chin 
than the occiput, and in so doing, she thinks, we only 
promote the natural prochvity of the head (1). 

This counsel deserves to be remembered, and ought 
to be acted upon whenever pressure against the forehead 
is abortive and there is difficulty in reaching the occi- 
put : to shght it would be inconsistent with our improved 
knowledge, and proportionate diminished dread, of com- 
plete face presentations. 

Secondly ; Version, or turning the child. — Among 
the conditions requisite for the safe performance of this 
operation, in any case, there is one of paramount impor- 
tance, viz., the presenting part must not have passed the 
uterine orifice, or have long occupied fully the pelvic ex- 
cavation. In the first instance, the cervix uteri is con- 
tracted above the part which has escaped, and in at- 
tempting to return it, there is danger of rupturing the 
womb; in the second, the uterus is contracted so closely 
about the child, if the membranes have been ruptured 
and the liquor amnii discharged, as is commonly the 
fact, that there is still danger of ruptm^e or other serious 
injury, in pushing the presenting part above the brim — 
an indispensable preliminary to the introduction of the 
hand. Looking to the interests of the mother, we ought 
not, therefore, to resort to version at an advanced period 
of labor in face presentations ; and we should as little 
think of it, at an early period, viz., as soon as the os 
uteri is dilated, and shortly or immediately after the 

(1) Pratique, etc., Memoire cit. 



374 FACE PRESENTATION. 



rupture of the membranes, when it may be most safely 
performed, because, as already stated, this would be 
groundless anticipation of difficulty. Turning, then, 
can seldom, if ever, be necessary or proper in these 
cases, for the safety or advantage of the mother; ac- 
cordingly, Madame Lachapelle, who seems to have had 
a penchant for the operation, pleads the danger to which 
the child is exposed, in justification of her frequent re- 
sort to it. '^ In my table, will be found," says she, 
"forty-one spontaneous deliveries in seventy-two face 
positions ; the remainder were terminated by art ; it is 
to be observed, though, that this great proportion of ar- 
tificial deliveries was not owing to any difficulty of la- 
bor or danger of the mother, but of the child." Her 
rule was, to deliver when the child is brought into a suf- 
fering or critical condition, which she judged to exist by 
the cessation of the movements of its tongue and jaw, 
and the increase of congestion. The child is not, how- 
ever, often in jeopardy, until the expulsion has advanced 
so far as to make it more or less perilous for the mother 
to deliver by turning; and under these circumstances, the 
prospect of rewarding her for the risk, by presenting 
her with a living child, as the fruit of the operation, is 
too slender to reconcile us to it. I know, indeed, that 
in the table referred to, Madame Lachapelle gives seven- 
teen living and three dead children, as the result of ver- 
sion in twenty cases; but in less-skillful hands, and 
among general practiti oners, the chances of success are not 
near so great; and it is doubtful whether one half would 
be brought into the world living, or long survive the in- 
juries received by the way. We are not told how many 
of the mothers lived to enjoy the triumph of obstetrical 



TREATMENT. 375 



art (a capital defect in the table), but it appears to be 
pretty well established that more women die from par- 
turition and its consequences, in French, than m British 
or American practice; and, with our views of the com- 
parative value of the hves of mothers and unborn chil- 
dren, we should say, that if one of these twenty women 
died, in consequence of the mode of delivery, the re- 
demption of the seventeen children, or rather, as many 
of them as would have been lost by other management, 
was too dearly purchased. 

From what has just been said, it may be inferred 
that version is not a favorite resort with me, in face pre- 
sentations, under any ckcumstances ; and I will take the 
present opportunity to declare, as my own opinion, that 
it is seldom defensible, for any reasons whatever, where 
the vertex presents. In such cases, it is the most arti- 
ficial of all the modes of delivery, with the single excep- 
tion, perhaps, of the Caesarian section : it subverts the 
purpose of nature, in the first place, by repelling the 
part which she so much prefers advancing, and then 
substitutes, to a greater or less extent, mechanical trac- 
tions for the vital agencies which she has appointed to 
preside over childbirth. When art has tasked her 
utmost ingenuity, the product is but a poor imitation of 
nature, in one of her most important vital functions — that 
which is designed for the propagation of life itself; the 
child may, indeed, be torn from its repository, but if the 
regular series of vital actions, which should have changed 
its habitation, be rudel}^ interrupted, there is no esti- 
mating the pernicious consequences, immediate and re- 
mote, which may result to the mother. 

Thirdly; The forceps or crotcliet. — When the face 



376 FACE PRESENTATION. 



has advanced so far in the pelvis, and the uterus is so 
closely contracted about the child, as to preclude turning 
or render it unsafe, the forceps affords the proper means 
of delivery, if the child be alive, or the crotchet, if it be 
dead. It is hardly necessary to observe that the for- 
ceps is not called for, hecaiise it is a face presentation ; 
though this may, for the reasons already given, more 
frequently require it than the vertex, but because the 
labor can no longer be intrusted to nature, safely for 
the mother and child. It is to be resorted to, therefore, 
upon the general principles that govern us in vertex 
cases, which it would be out of place to discuss here. 
But with regard to the manner in which the head is to 
be extracted, it may not be amiss to advert to a singu- 
lar and gross mistake committed by Dr. Dewees. This 
appears to be the more necessary, because his writings 
are in the hands of all practitioners in this country, and 
are the guide of not a few. 

Dr. Dewees directs, very properly, that the blades 
of the forceps be applied over the ears, and then erro- 
neously observes that " they must be so appHed that 
the concave edges must look toward the hind head, 
which must be brought under the arch of the pubes, and 
not the chin, as directed by Smellie" (1). If he had 
not been so careful to forbid what is right, we should 
have supposed that his inculcation of what is wrong was 
a lapsus pennse, or a typographical error. 

Now, in no case is the precept, to deliver in accord- 
ance with the mechanism, more obligatory on the prac- 
titioner than in face presentations. How strong the 

(1) Midwifery, fifth edition, p. 313. 



TREATMENT. 377 



tendency of the chin toward the pubes is, we have seen, 
and, also, how essential its revolution thither, rather than 
into the hollow of the sacrum, which raises almost an 
insurmountable barrier to the head's expulsion, and for- 
bids the hope of extracting the child ahve by the for- 
ceps. SmeUie understood these cases much better than 
Dr. Dewees. In one of his cases {JVo. IV, Collect 
XXX), where he found, when called by a midwife, the 
anterior fontanel at the pubes and the mouth and chin 
toward the sacrum, and where the womb was so strongly 
contracted as to defeat an effort to turn, he applied the 
forceps and endeavored to bring the head lower down ; 
he then tried to turn the chin, first to one side and then 
to the other, — which he finally succeeded in accom- 
plishing by first raising the head in the pelvis, — 
and eventually brought it out under the pubes, safe- 
ly for the child as well as the mother. In his 
next case ( ^Yo. F, Colled, eadem ), he extracted the 
head with the forceps, truly, as he found it, viz., with 
the chin to the lower part of the sacrum, though a little 
to the left side; but the woman had been long in labor, 
the face was so low down as to protrude the external 
parts in form of a tumor, and she was delivered of a 
dead child. 

From this discussion, it may be concluded that, in 
full face presentations, we are neither to redress the 
head, nor turn, nor use the forceps, merely because the 
face presents : it may, then, be inqmred, is any special 
treatment demanded in such cases ? 

It has been supposed that great vigilance is neces- 
sary, on the part of the accoucheur, to prevent the chin 
from rotating toward the hollow of the sacrum, and to 



378 FACE PRESENTATION. 



insure its turning under the pubic arch. '' To give all 
possible aid and assistance to nature, in her attempts to 
turn the chin toward the front of the pelvis/' is inculca- 
ted by Professor Meigs as the prime duty of the medi- 
cal attendant, in these cases. Again he says, "the 
great doctrine," in all face positions, is to bring the chin 
to the pubic arch: "there are," he continues, "two po- 
sitions, in which the chin naturally tends to the arch, 
if the position be just and good; or it may tend to fall 
into the sacral curve, if it be not just and good " (1). 

Such solicitude about the destination of the chin 
appears to me altogether unnecessary; the pubic arch 
is prescribed for it by nature, and, as a rule that has 
very few exceptions, thither it tends and will be ulti- 
mately landed. It is fortunate for the parturient wo- 
man that there is this strong natural proclivity ; for it is 
exceedingly doubtful whether it is at all in our power to 
control the movement of the chin, by any force that 
can be exerted by the hand, and we should be loath to 
use instruments for such a purpose. With due defer- 
ence for the opinions of Professor Meigs, I would, there- 
fore, say, that to have all reasonable confidence in ih^ 
ability of nature to accomphsh what she purposes, is our 
first duty in these cases. The labor should be allowed 
to take its course, just as in vertex cases, unless palpa- 
ble necessity of assistance should be developed during 
its progress, and the more efficient aid than can be given 
by the fingers, attempting to direct the course of the 
chin, will be required; — the head must be extracted by 
the forceps. 

(1) PhiladelpMa Pract. Midwifery. Chapter on Face Pre- 
sentation. 



TREATMENT. 379 



The precaution that is to be observed in supporting 
the perineum, when the face is about emerging, is another 
item of special treatment, which Madame Lachapelle 
thought of sufficient importance to be attended to. "In 
sustaining the perineum," she remarks, "it must be 
remembered, that the chin is engaged in the arch, that the 
anterior part of the neck is pressed against the posterior 
face of the pubes, and that the throat rests upon the 
border of the arch, as its prop. We must be cai^eful, 
therefore, not to push strongly upward and forward, 
whereby the danger to which the child is exposed would 
be greatly enhanced : the head must be simply sustained, 
and not pushed" (1). The injury which Madame 
Lachapelle apprehends might be inflicted on the child, 
is, of course, contusion of the superior part of the neck, 
where it is pressed against the inferior border of the 
pubic bones, which appears to me imaginary. The face 
can only be released by undergoing flexion; and of this 
movement, the guttural region of the neck being the 
pivot, considerable compression, and some contusion of 
it, are unavoidable. It is doubtful whether weU-regula- 
ted pressm^e upon the perineum will materially augment 
the contusion ; and, at all events, we should be quite 
unwilhng to be deprived of the privilege of giving such 
valuable assistance, as is often in our power, by this 
means, as weU in face as in vertex presentations. By 
well-regulated pressure, I mean pressure made with the 
hand, or both hands, according to ckcumstances, bearing 
with greatest force upon the perineum posteriori}^, and 
directed from the os coccygis to the pubes : having for its 

(1) Troisieme Memoir e. 



380 FACE PRESENTATION. 



object; the promoting of the particular movement which 
the head has to execute in escaping at the vulva; 
) extension in vertex, flexion in face, positions.) Of the 
efficiency of such pressure, in vertex cases, I have 
already expressed my strong conviction; and it may be 
confidently stated, that, if the assistance of art is some- 
times needed in vertex presentation, it is still more 
likely to be needed in face cases; because, flexion, for 
reasons already given, is more difficult than extension. 



SHOULDER PRESENTATION. 381 



CHAPTER XXI. 

SHOULDER PRESENTATIONS — THEIR MECHANISM, 
DIAGNOSIS, AND PROGNOSIS. 

In the notice that has been taken of them, in a pre- 
vious chapter, presentations of the shoulders were con- 
sidered in connection with each other, nor is there now 
any necessity of separating them. When either shoul- 
der presents, the body of the fetus is placed more or less 
transversely in the uterus; and it is physically impossi- 
ble that it can be born, by the unaided efforts of na- 
ture, unless its position be changed, or it be amassed in 
an unusual manner. Such a presentation may, there- 
fore, with strict propriety, be regarded as preternatural. 
It does, nevertheless, occasionally happen, that the na- 
tural resources are, by an extraordinary exertion, suffi- 
cient for the exigency; and the mechanism by which 
this is accomphshed deserves to be studied, not only 
as curious, but as affording useful hints to us in prac- 
tice. 

Dr. Denman, who first directed the attention of the 
profession to the subject, denominated the movement, 
by which nature contrives to expel the fetus in these 
cases, spontaneous evolution — a vague appellation, ex- 
pressive of the result, rather than the expedient adop- 
ted for its attainment. Spontaneous version would have 



382 SPECIAL PHENOMENA OF SECOND STAGE. 



been a more proper phrase, considering the views which 
he entertained in regard to nature's procedure; for he 
says, "As to the manner in which this evolution takes 
place, I presume that after the long-continued action of 
the uterus, the bod}^ of the child is brought into such 
a compacted state, as to receive the full force of every 
returning action. The body in its doubled state, being 
too large to pass through the pelvis, and the uterus, 
pressing upon its inferior extremities, which are the 
only parts capable of being moved, they are forced gra- 
dually lower, making room, as they are pressed down, 
for the reception of some other part into the cavity of 
the uterus which they have evacuated, until the body 
turning as it were upon its owm axis, the breech of the 
child is expelled, as in an original presentation of that 
part"(l). 

Dr. Denman's explanation was generally received as 
a satisfactory solution of the phenomenon, until it was 
objected to by Dr. Douglass, of Dublin, in a pamphlet 
entitled, "Explanation of the real process of the spon- 
taneous evolution of the fetus," which I have never seen, 
but the substance of which may be gathered from the 
references to it by subsequent systematic writers. Con- 
trary to the declaration of Denman, Dr. Douglass main- 
tained that the fetus actually does pass the pelvis in a 
doubled state ; first, the shoulder and chest are pro- 
pelled low in the pelvis, when the whole of the arm is 
made to protrude externally; the acromion then appears 
under the symphysis pubis, and as the loins and breech 



(1) Introducton to the Practice of Midwifery, chapter 14, 
section 8. 



SHOULDER PRESENTATION. 383 



descend into the pelvis at one side^ the apex of the 
shoulder rises toward the mens veneris, making room for 
the complete reception of the breech into the cavity of 
the sacrum; and thispart is eventually expelled, greatly 
distending the perineum, to be followed by the other 
shoulder and arm, and lastly the head " (1). 

Considered as a description of what occurs, in the 
great majority of instances of natural expulsion, in 
shoulder presentations. Dr. Douglass's narration must 
be reckoned to be, in the main, faithful ; but his rea- 
soning against Dr. Denman's hypothesis is not entitled 
to much weight, when he observes, " that it is incom- 
patible with the received ideas of uterine action to sup- 
pose that the uterus, when contracting so powerfully as 
to force down that part of the child which was at its 
fundus, could at the same moment form a vacuum, into 
which another portion, akeady low down in the peMs, 
should recede." There is nothing more impossible, as 
Dr. Burns truly remarks (2), so far as uterine contrac- 
tion is concerned, in the child revolving during the ac- 
tion of the uterus, by the efforts of the womb on the 
upper end of the elKpse ( the nates ), than that we 
should, during the uterine contraction, find the shoul- 
ders with facility go up, merely by drawing gently at 
the feet ; and, we may add, in a certain number of cases 
( the proportion being probably small ), nature does 
proceed after this manner, performing a genuine version 
of the child. Still, it undoubtedly is according to the 
other manner, described by Dr. Douglass, that nature 

(1) Ramsbotham's Process of Parturition. 

(2) Principles of Midwifery. 



384 SPECIAL PHENOMENA OF SECOND STAGE. 



usually operates ; and this I propose to call the duplica- 
tion, instead of the spontaneous evolution, of the fetus. 

The expulsion of the child, by the process of dupli- 
cation, is pretty well described by Dr. Douglass; but it 
may not be amiss to study its mechanism somewhat 
more particularly, availing ourselves of the valuable as- 
sistance of M. Cazeaux, to whom we are already so 
largely indebted. For this purpose we may take the 
first or scapido-pubic position of either shoulder, for, in 
this respect, there is no essential difference between 
them ; but we select, with M. Cazeaux, the first posi- 
tion of the right shoulder, in which, it will be remem- 
bered, the head of the child is placed in the left iliac 
fossa, the breech in the right iliac fossa, its back look- 
ing forward, and its breast backward. Its great axis 
corresponds nearly with the transverse diameter of the 
pelvis. 

After the rupture of the membranes and the imme- 
diate escape of nearly all the liquor amnii, the uterus is 
brought into close embrace of the fetus, and causes the 
presenting part to engage in the excavation : and now 
commences what may be called the first step, viz., 
flexion and descent, which I unite, although M. Cazeaux 
makes of them two distinct steps. This first step is 
performed in the following manner: — the great axis of 
the fetus is strongly flexed upon the side opposite that 
Avhich presents, the head is thrown upon the left side, 
and the breech upon the flank of the same side. While 
this flexion is going on, the shoulder descends lower and 
lower in the pelvis, until its progress is arrested by the 
neck, whose shortness will not permit the shoulder, any 
more than the face, in face positions, to reach the bottom 



SHOULDER PRESENTATION. 385 



of the pelvis, and for the same reason ; that is, its length 
is not equal to that of the lateral wall of the excavation. 
A rotatory movement now occm^s, as the second 
stej?, by which the axis of the trunk is placed nearly 
antero-posteriorly, instead of transversely as it was; the 
head is brought over the horizontal branch of the pubis, 
and the breech before the sacro-iliac symphysis; and 
now the descent can be completed, — since the side of 
the neck is behind the symphysis pubis, the depth of 
which is not greater than its length. The arm now 
escapes or protrudes at the vulva, and the shoulder 
comes under the symphysis pubis. 

The shoulder not being able to advance further, on 
account of the hinderance of the neck, and the expulsive 
force continuing to act on the nates, the doubled body 
of the child is pushed into the excavation, and sweeps 
over the concavity of the sacrum and along the peri- 
neum, which is greatly distended. The third and final 
step is now taken, viz., disengagement, or, as it is very 
properly called by M. Cazeaux, deflexion, which is exe- 
cuted by the shoulder remaining stationary, under the 
pubes, while the side of the chest, the side of the loins, 
the hip, and lastly, the thighs and the whole of the infe- 
rior extremities successively, emerge before the anterior 
commissure of the perineum. The head and the left 
arm only remain, and these are easily expelled. 
I The mechanism is not materially different in the 
' second or scaindo-sacral position of either shoulder ; but 
I M. P. Dubois, as we learn from M. Cazeaux, has ob- 
I served in two cases of this kind, that at the moment 
I when the nates were being disengaged before the ante- 
r rior commissure of the perineum, the entire trunk was 

; 25 



386 SPECIAL PHENOMENA OF SECOND STAGE. 



twisted so as to bring the back of the child forward, 
toward the pubes, which would otherwise have been 
directed toward the anus : so that even here the general 
law continues to reign, by which it is provided that, no 
matter zvhat may he the primitive relation of the poste- 
rior plane of the fetus, it is ultimately turned toward 
the anterior part of the pelvis; — a law as salutary as it 
is wonderful. 

Diagnosis. 

Previous to the rupture of the membranes, it is not 
possible to ascertain, certainly, the presence of the 
shoulder at the superior strait. From the form of the 
uterus, viz., its unusual width, in connection with the 
elevation of the presenting part, which cannot be reached 
by the finger, and more especially if a small, floating 
member of the fetus can be felt, we may suspect that 
we have to do with a shoulder presentation, but cannot 
attain to certainty, until the membranes have ruptured 
and the shoulder is somewhat engaged in the pelvis. 
Then it may be either the shoulder proper, or the elbow 
and side of the child, which offers at the center of the . 
superior strait, — the acromial and cubital varieties of 
Madame Lachapelie, — and the marks, which will be 
recognized by the touch, will be different, as one or the 
other of these varieties may chance to be present. 

The shoulder is distinguished by the round tumor it 
forms, not so large or so resisting as the head, for which 
it can scarcely be mistaken, neither is it so large as the 
breech, but its consistency is about the same, and hence 
it has been mistaken for it. But, by carrying the finger 
sufficiently high, we may be able to feel the acromion 



SHOULDER PRESENTATION. 387 



process and spine of the scapula, the clavicle, the arm- 
pit with its margins, and, if the child be not very fat, 
the ribs and the intercostal spaces, — all, or even several, 
of which will serve to distinguish the shoulder from any 
other part. Our next aim is to determine which 
shoulder presents and what is its position, and this can 
be learned by attending to the relations of the lack and 
armpit of the child to the pelvis of the mother. In 
the first position of both shoulders, the back of the 
child and arm proper (humerus) are forward, while the 
forearm and hand flexed upon the sternum are toward 
the sacrum of the mother. The scapula will indicate 
the location of the back ; and supposing this first position 
to exist, if the armpit is directed toward the right ilium 
of the mother, it is the right shoulder, if toward the left 
ihum, it is the left shoulder. In the second position of 
both shoulders, the back of the fetus and arm are placed 
posteriorly, the flexed forearm and hand anteriorly, and 
if now the armpit is toward the right ihum, it is the 
left shoulder, if toward the left ilium, it is the right 
shoulder. 

The elbow is distinguished by its three bony pro- 
cesses, the olecranon and the condyles of the humerus, 
by the prominence of the tendon in its bend, and the 
vicinity of the chest, with its ribs and intercostal spaces. 
If our examination be limited to the elbow, it might be 
mistaken for the heel of the fcot; but the elbow is 
smaUer and more pointed, and the condyles are not so 
remote from it as are the maUeoli fi-om the heel. Should 
any uncertainty be felt, it may be removed by tracing 
the forearm to the hand, which may be readfly distin- 
guished from the foot, by the marks formerly given. 



388 SPECIAL PHENOMENA OF SECOND STAGE. 



The elbow once clearly recognized, we are enabled, by 
it alone, to ascertain the shoulder that presents and its 
position. If the forearm is backward, it is the first po- 
sition; and if the elbow is toward the right, it is the 
right shoulder; if toward the left, it is the left shoulder. 
The forearm being forward, denotes the second position; 
and then the elbow being toward the right, it is the left 
shoulder; and being toward the left, it is the right 
shoulder. 

In shoulder presentations, the arm is not unfre- 
quently extended, and is found hanging in the vagina, or 
protruding through the vulva. This does not obscure, 
but rather facilitate^ the diagnosis, provided we be care- 
ful to ascertain that it is a precursor of the shoulder, 
and not of the head, for procidence of an arm some- 
times complicates head presentations. An arm having 
prolapsed, we may easily ascertain whether it be the 
right or left, by applying the palm of our hand to its 
palm; if its thumb corresponds to our thumb, it is the 
right hand ; but if its little finger correspond to our 
thumb, it is the left hand, and its thumb will corres- 
pond to the thumb of our left. Having learned, in this 
way, which shoulder presents, we can ascertain its posi- 
tion by passing a finger or two along the arm to the 
armpit (which should be done, at any rate, to make 
sure that the shoulder is above it); if it is the right 
arm, the armpit is toward the right side in the first posi- 
tion, and toward the left in the second ; if it is the left 
arm, the armpit is toward the left side in the first posi- 
tion, and toward the right in the second. Both the pre- 
sentation and the position are so clearly indicated by 
the prolapsed arm, that it will be proper, in all cases of 



SHOULDER PRESENTATION. 389 



doubt and perplexity (and who has not met with such ?), 
to bring down an arm to enhghten the diagnosis, espe- 
cially as such a procedure will not at all embarrass the 
treatment of the case. 

Prognosis. 
These presentations have, in all ages and countries, 
been regarded as sinister, and as requiring the interpo- 
sition of art, to surmount the difficulties which they op- 
pose to childbirth. Such an opinion could hardly have 
gained currency and maintained its ground, were there 
any sufficient foundation for the more favorable estimate 
of the powers of nature, which Dr. Denman was pleased 
to entertain. In his opinion, "a woman in a state of 
nature, ivitli her child fresenting in any manner^ would 
not die undeHvered, if no assistance were afforded to 
her;" but, in a country "somewhat civilized," much 
would be thought requisite to be done for an equally 
healthful woman, and she might fall a sacrifice to "the 
ungainly and rude exercise of art, " — the attempts of 
art defeating the natural efforts. In the instances of 
women dying undelivered, their children presenting 
with the arm, because it Avas not possible to pass the 
hand into the uterus, to turn the child and deliver by 
the feet, communicated to Dr. Denman, by his medical 
friends, he more than hints, that spontaneous evolution 
was hindered by the efforts that were made to turn. It 
may be true, that natural expulsion would have taken 
place, in many more instances than have been witnessed, 
if practitioners had never interfered; and yet, there is 
reason to believe, that many more women must have 



390 SPECIAL PHENOMENA OF SECOND STAGE- 



died, either undelivered, or in consequence of the se- 
verity of the labor, under this expectant treatment, 
while it is well ascertained that but few of the children 
could have survived. The records of these cases show 
clearly, what their very nature might have authorized 
us to predict, that the labors were terminated after 
severe and long conflicts, compromiting the mothers, 
who were not always so fortunate as to escape death, 
and destroying the greater part of the children, — one 
hundred and twenty-five of the one hundred and thirty- 
seven, whose fate has been communicated by M. 
Velpeau. 

With such evidence as this before us, we should not, 
ivillingly^ confide shoulder presentations to unaided na- 
ture, however much we may admire the fertility of her 
resources, and however gratefully we may acknowdedge 
the overwhelming power which she occasionally brings 
to the rescue, when the help of man is vain. On the 
contrary, it is our duty to lighten her burden, and con- 
sult the safety of both mother and child, by turning, 
and thus adjusting the axis of the child's body to the 
axis of the parturient passages, whenever this can be 
done with any degree of facility, and with a due regard 
to the safety of the mother. There are, nevertheless, 
cases in which we shall be justifiable in deferring to act, 
in hope that the child may be expelled by the process 
of duplication ; as for example, in premature labor, 
where the small size of the child warrants the expecta- 
tion that it may easily pass, doubled upon itself; or 
where, in labor at the full period of pregnancy, the 
pains are unusually powerful and frequent, and the child 



SHOULDER PRESENTATION. 391 



is already forced so low down in the pelvis as to distend 
the external parts. A remarkable instance of the 
latter kind, which came under my own observation, I 
may be permitted to relate. February 27, 1846, I was 
requested by Dr. Donne, now one of the professors in 
the Memphis Medical College, to accompany him to the 
house of Mrs. B., on Market street, who was in labor 
with her second child, under the disadvantages of a 
shoulder presentation. I found Dr. Lewis Rogers at 
the house, who had made an effort to turn, but 
was defeated by the strength of the uterine contrac- 
tions. It was plain, from the patient's behavior, 
that the pains were still exerted with unusual vehe- 
mence as well as frequency, and I proceeded, as soon 
as possible, to make an examination; when it w^as 
discovered that the left shoulder presented in the second 
{scapulo-sacral) position, with the arm extended and 
the hand protruding through the vulva. Before the ex- 
amination was completed, however, the perineum began 
to be distended, and I remarked to the medical gentle- 
men, that the child would probabty be expelled by du- 
phcation, which did accordingly occur in a few moments 
afterward, in the manner already described. The 
child, which appeared to be fully developed and of aver- 
age size, was born dead; its left arm being considerably 
swollen, and the left side of the neck, with the corres- 
ponding cheek, retaining marks of the contusion they 
had suffered. The labor was not unusuall}^ protracted, 
and the mother recovered without any unfavorable con- 
sequences. It should, perhaps, be observed, that the 
time when this case happened seemed to be propitious 



392 SPECIAL PHENOMENA OF SECOND STAGE. 



for independent chilclbearing; as no fewer than four 
women^ to whom I was called, were deHvered by dame 
Nature, before I could reach their domicils, albeit I 
made as much haste as is consistent with obstetric 
dignity. 



SHOULDER PRESENTATION. 393 



CHAPTER XXII. 
TREATMENT OF SHOULDER PRESENTATIONS. 

Treatment. — The great desideratum^ in shoulder 
presentations, is, to restore the fetus to a situation in 
the cavity of the uterus, that win enable it to pass out 
of the pelvis, under the influence of the parturient 
forces, with the assistance of art. This, it is evident, 
will be fulfilled by pushing aside the shoulder and bring- 
ing either the head or the nates into the pelvis, thus 
causing the child to turn upon its axis, and offer one of 
its extremities to the passage. The manual operation, 
by which this is effected, is denominated turning or ver- 
sion of the child : and according as the head or the 
nates is brought down, it is cephalic or j^elvic version. 
Cephalic version has but few advocates at the present 
day, and is confessedly apphcable to such a limited num- 
ber of cases, that it is scarcely worthy of our formal 
consideration. For this reason, and also because I have 
no experience of it, I shall confine my obserA^ations to 
pelvic version, or the operation of bringing the feet 
through the vulva, in order that the child may be born 
without such mechanical disadvantages as belong to 
shoulder presentation. 

Before describing the manner of turning, in the dif- 
ferent positions of the shoulders, it will be useful to 
offer some general observations on this mode of dehvery. 



394 SPECIAL TREATMENT OF SECOND STAGE. 



These general observations will relate to the conditions 
that must exist to justify the operation, the position of 
the patient, the choice of a hand, and the principles that 
should govern the several parts into which the operation 
may be divided. 

Conditions. — The operation ought not to be under- 
taken, and there is seldom, if ever, necessity of under- 
taldng it, until the os uteri is sufficiently dilated to 
allow the hand to enter the cavity of the womb, with- 
out the employment of any considerable force. It is 
not necessary that the orifice should be so patulous as 
to admit the hand without the least resistance, for thus 
it may not be, and yet be so far dilated and dilatable 
withal, that the hand may enter it, without such force 
as would prove, in the least degree, injurious. But vio- 
lence is always to be avoided, as never justifiable and 
often destructive. If the operator has the selection of 
his time, the most favorable moment is, unquestionably, 
just when the os uteri is sufficiently dilated for his pur- 
pose and before the membranes have ruptured, for he 
may then rupture them and immediately push his hand 
into the uterine cavity, before the waters have escaped. 
He will thus have the signal advantages of ample room 
for the movements of his hand, free access to the feet of 
the child, and great facility in turning. But, unfortu- 
nately, this favorable conjuncture is not often enjoyed, 
at least in the practice of this country, where the physi- 
cian may not be called until it is irrecoverably lost, and 
his services are requested only on account of the subse- 
quent discovery that the shoulder is presenting. The 
operation is then to be performed, with the hinderance 
resulting from more or less close contraction of the ute- 



SHOULDER PRESENTATION. 395 



rus about the child's body, according as the hquor am- 
nii is more or less completely discharged, and little or 
none will be retained, after the lapse of a few hours, for 
the shoulder is a worse stopper of the orifice than even 
the breech. 

If a considerable time have elapsed since the rup- 
ture of the membranes and escape of the waters, the 
uterus may be so strongly contracted as to defeat any 
attempt to introduce the hand into its cavity, and com- 
pel us to devise some other expedient to deliver the 
woman. What is to be done, in this case, will be pre- 
sently pointed out and explained: but let not the prac- 
titioner too hastily conclude that delivery by turning is 
impracticable, for I have often found that, notwithstand- 
ing I have been fiaistrated in a first or second trial, by 
persevering and varying the maneuver somewhat, suc- 
cess has ultimately crowned my efforts. The operation 
may sometimes be facihtated by bloodletting and tartar- 
ized antimony, administered in broken dozes, at short 
intervals, until nausea or even sHght vomiting is in- 
duced, and one or both of these, according to circum- 
stances, ought to be tried before it is finally relinquished. 

Position of the patient. — The patient must be placed 
across the bed, upon her back, and with the hips so near 
the side of the bed that the perineum projects a little 
over the mattress on which she lies. Her feet may rest 
on chaks, or in the laps of two assistants, who are 
charged with keeping her knees far enough apart to 
make room for the operator to stand or sit between them. 
A sheet or blanket, according to the season, must be 
thrown over her to screen the patient fi'om exposure, which 
is as indehcate as it is unnecessary ; for the operation, 



396 SPECIAL TREATMENT OF SECOND STAGE. 



from first to last, is to be performed under the guidance 
of the touch alone. The necessity of having the peri- 
neum free of the bed arises from the course of the hand, 
in its complete introduction, which is that of the axis of 
the superior strait ; and this cannot be followed without 
depressing the elbow to the level of the bed. So great 
must this depression be, when the feet of the child lie 
in the anterior part of the uterine cavity, that it is some- 
times less irksome to the physician to have the patient 
turned upon her side. 

Choice of a hand. — Not a little discrepancy will be 
found among practical writers, in the directions they 
give as to the hand that should be employed, in the 
different shoulder positions. Without discussing the 
merits of their conflicting advice, I shall be content to 
state my own rule, which is, that the right hand must be 
used for the right shoulder, and the left hand for the 
left shoulder. Where there is obscurity or uncertainty 
as to the presentation, the right should be preferred, 
because it is that which most persons are accustomed to 
employ, and can, therefore, use with the greatest facil- 
ity. The choice of a hand for the operation implies a 
perfect knowledge of the presentation, which ought, in 
fact, always to be attained, whenever it is practicable, 
before commencing the operation. This is the more 
necessary where the uteius is in a contracted state, as, 
by guiding the hand in the right direction, namely, 
toward the feet, we shall be saved a deal of toil, and the 
patient of pain, which must result from passing the 
hand in a wrong direction, and then having to withdraw 
it in order to get into the proper track. 

With a view to the more methodical description and 



SHOULDER PRESENTATION. 397 



study of the operation of turning, it may be divided 
into three parts, viz., 1, Introduction of the hand into 
the uterme cavity; 2, Seizing and bringing down the 
feet; 3, Extraction of the child. The principles that 
should govern us, in the performance of these several 
parts, are next to engage our attention. 

1. Introduction of the hand, — The hand selected 
for the operation, and likewise the forearm, must be well 
lubricated with lard, with the exception of the palm, 
which ought not to be greased, that it may take a firmer 
hold of the legs. The operator is, of course, to divest 
himself of his coat, and roll up the shirt sleeve of the 
arm which is to be used. Some practitioners are fastidi- 
ous on this point, fearing that such preparation will give 
them too much of a butcher-like aspect ; but this is cer- 
tainly neater and less frightful than to have the shnt 
sleeve dangling about the arm, soaked with blood and 
other fluids, as I have sometimes seen it in the lying-in 
chamber. The hand, thus prepared, is to be formed into 
a cone, by pressing the fingers together and flexing the 
thumb on the palm, and must be presented to the exter- 
nal organ, with its breadth correspondiug to the genital 
fissure. By pressing on the perineum, the external ori- 
fice can be gradually dilated, so as to receive the entire 
hand, which is now lodged in the vagina. In effecting 
this part of its intromission, the hand must move in the 
direction of the vagina, which is that of the axis of the 
inferior strait, that is, upward and backward; and it 
will be best to act only during the pains , as the severer 
suffering of the throes of labor will render the patient 
unconscious of the pain inflicted by the hand. The ute- 
rine cavity is now to be entered, and to accompHsh this, 



398 SPECIAL TREATMENT OF SECOND STAGE. 



the hand must preserve its conical form, and the resist- 
ance of the OS uteri, if any exist, must be overcome by 
gi-adual dilatation. These dilating efforts must be made 
only in the intervals of the pains ^ and when the hand is 
fairly introduced, it must be pushed forward as rapidly 
as may be toward the feet. Let it never be forgotten, 
however, that, especially when the uterus is closely con- 
tracted, the hand, in its farther progress, must rest during 
the pains, and He flat upon the surface of the child's body, 
ready to resume its march the instant the pains cease, that 
the most may be made of every interval of the muscular 
contractions. The movement of this hand will be facil- 
itated, by applying the other to the abdomen of the 
mother, for the purpose of steadying the uterus and pre- 
venting its ascension, which might not only hinder this 
part of the operation, but occasion rupture of its vaginal 
connections. 

2. Seizing and bringing down the feet. — The hand 
having arrived at the feet, takes a secure hold of them, 
by inserting the index between the internal malleoH, 
while the thumb is applied to the outer part of the an- 
kle of one leg and the other fingers to the outer part of 
the other ankle. Embracing the opportunity offered by 
an interval of the pains, the operator is to bring the 
feet down over the child's abdomen, as much as possible 
in the direction of the natural flexure of the body; and 
this evolution may be assisted by the hand that is ap- 
plied externally, which must push the head upward to- 
ward the fundus of the uterus. When the womb is 
strongly contracted, it is not always easy to seize both 
feet; the practitioner ought then to be satisfied with 
one, and proceed to make 'the evolution by drawing it 



SHOULDER PRESENTATION. 399 



down. I have several times adopted this course^ and 
considered myself fortunate in getting hold of one foot. 
Again : it may happen^ under the same circumstanceSj 
that the feet cannot be reached at all; in that case, the 
turning may be effected by acting upon the knees, or 
upon one knee, by means of two fingers apphed to the 
ham, and then one or both legs can be extended and 
brought out of the vulva. 

3. Extraction of the cliild. — When the child's feet 
are brought through the vulva, it would, undoubtedly, 
be proper to confide the completion of labor to nature, 
if sufficient power be retained by the uterus, and be so 
vigorously exerted as to give promise of a satisfactory 
issue. But this rarely, if ever, happens, in the cases we 
are considering; for the labor has generally been te- 
dious, and the uterine force, more or less, completely 
expended, before we are called on to deliver, and it is 
then our indispensable duty to extract the child. This 
part of the operation must, however, be executed, in as 
close conformity as possible to the natural procedure. 
If there be pains, no matter how feeble, our extractive 
force should act only in concert with them; and, if 
there be no pains, we should extract, not continuously, 
but with intervals of rest, in imitation of nature. Each 
application of artificial force ought, moreover, to be 
made with gradually augmenting strength, and be as 
gradually relaxed, for this, too, is nature's method. As 
to the movements that the body of the fetus is to be 
caused to execute, they are precisely such as belong to 
the mechanism of labor, in nates presentations ; and the 
manner of proceeding, in order to secure these, having 



400 SPECIAL TREATMENT OF SECOND STAGE. 



been already explained in the chapter on that subject, 
we need not repeat what is there said. 

In the extraction of the child, after turning, there 
is, however, one thing to be attended to, which hardly 
merits attention in the management of nates presenta- 
tions, because the vigilance of nature exonerates us 
from solicitude concerning it, — I mean the care which 
the operator is to take to turn the anterior parts of its 
body toward the loins of the mother, while he is enga- 
ged in extracting it. The sufficiency of nature, in 
original nates cases, arises from the uterus possessing 
and exerting its forces, in a good degree, needing only, 
at most, the assistance of the accoucheur; and the ten- 
dency of these forces being to cause so desirable a revo- 
lution of the child's body, even where its abdomen is 
toward the pubes, primitively. But in shoulder presen- 
tations, the delivery is more artificial : and should the 
toes point forward, when the feet are brought out, the 
head may come into the pelvic excavation, with the face 
toward the pubes, and its extrication be thus rendered 
much more difficult. To prevent, if possible, such a 
catastrophe, the operator ought to make traction upon 
the leg that is toward the pubes, which tends, in the 
gentlest and most gradual way, to turn the anterior 
parts of the child's body posteriorly; so that when 
the head is brought into the pelvis, the face may be in 
the hollow of the sacrum. To effect a so desirable ob- 
ject, most writers direct more vigorous exertions — even 
the grasping of the child's body, and forcibly turning it 
round; but such a maneuver is not free from serious 
objections, in all cases where the uterus is firmly con- 
tracted. In the first place, the head may not follow the 



SHOULDER PRESENTATION. 401 



rotation of the body, being hindered by the firm em- 
brace of the fundus of the uterus ; and thus the neck 
may experience a fatal twist, for its articulation with 
the head will not permit rotation equal to half a circle. 
In the second place, supposing the head to obey the im- 
pulse communicated to the body, the arms may not;^ and 
one of them may be made to decussate the back of the 
neck, when the head gets into the pelvis, and offer a 
serious barrier to its egress. Two kinds of decussation 
are distinguished by M. Duges, according as the acci- 
dent occurs at a more or less advanced stage of the ex- 
traction. If, when the body is turned round, the arm 
is pendent by the side, it first crosses the back, and then 
moves upwardly as the body is extracted, until finally, it 
is lodged upon the back of the neck. If, on the con- 
trary, the arm be raised alongside the head, when the 
body is made to revolve, the arms and the head only 
remaining in the uterus, the arm is depressed and sinks 
beneath the occiput. The first kind of decussation is, 
according to Duges, recognized by the inferior angle of 
the scapula being made to approach very near the 
spine, and the forearm is sometimes found hanging 
down the opposite side; in the second kind, the inferior 
angle of the scapula is removed to a greater distance 
from the spine, and the forearm is never pendent, but 
raised along the opposite side of the head. 

To discriminate between the two kinds of decussa- 
tion is material 'in practice, because their treatment is 
very different, — the first or ascending decussation, as it 
may be called, requiring the arm to be brought down 
over the back, and the second or descending requiring 
the arm to be pushed up over the head and brought 
26 



402 SPECIAL TREATMENT OF SECOND STAGE. 



down over the breast, — but to avoid the maneuver, 
likely to produce such an embarrassing accident, is still 
more important. If, therefore, the uterus be strongly 
contracted, and simple traction upon the member that is 
forward should not cause the child's anterior parts to turn 
toward the mother's back, it will be better to allow the 
head to come into the pelvis, with the face toward the 
pubes, and trust to our ability to rotate the face into 
the hollow of the sacrum, should it prove impossible to 
extract it, in its untoward position. Such is the prac- 
tice recommended by Madame Lachapelle, and Duges 
avers that it is not difficult to turn the face into the 
hollow of the sacrum, by the manipulation of that dis- 
tinguished midwife. The manipulation referred to, con- 
sists in introducing the hand behind the occiput and 
passing it over the opposite cheek until the fingers 
reach the mouth, into which one finger may be inserted ; 
the face, being thus seized, is to be drawn into the 
sacral concavity, at the same time that it is brought lower 
in the pelvic excavation, being made to move in a spiral 
line. For this manipulation the right or the left hand 
is to be used according as the face may be toward the 
right or left side of the pubes: should it look directly 
toward the pubes, either hand may be used indiffer- 
ently. 

These general observations being premised, we are 
prepared to consider the operation of turning in the 
several positions of shoulder presentation, commencing 
with the second position of both shoulders, because in 
these the operation, though it may not be more easily 
executed, is more regular, that is, more in conformity 



SHOULDER PRESENTATION. 403 



with our general rules, tban it may be practicable to 
make it in the first position. 

1. Turning in the second or scapiilo-sacral position 
of the right shoulder. — Let the student recall to mind 
the relations of the child's body, in this position: its 
back is toward the loins of the mother, its head is in the 
right iliac fossa, and its lower extremities, folded upon 
the abdomen, are contained in the left anterior part of 
the womb. The operator introduces his right hand in 
the state of supination, seizes and pushes the right 
shoulder toward the right iliac fossa of the mother, and 
then ghdes the hand over the posterior parts of the 
child's body until it reaches the breech. The hand 
is then brought forward, becoming prone as it rounds 
the breech, to get hold of the feet, which are drawn to- 
ward the child's abdomen, in bringing them down into 
the vagina, and thus this position is converted into first 
position of the nates. The extraction is then to be 
made in comphance m\h the rules already laid down; 
and no difficulty can be experienced in gi'adually rota- 
ting the anterior parts of the child backwardly, so as to 
bring the occiput behind the pubes. 

2. Turning in the second or scapido-sacral position 
of the left shoulder. — In this position, the back of the 
fetus is directed posteriorly, its head is in the left iliac 
fossa, and its legs are in the right anterior part of the 
uterus. The left hand is introduced supine, pushes the 
shoulder toward the left iliac fossa, traverses the back of 
the child, becoming prone as it passes over the breech, 
grasps the feet, and brings them down into the vagina, 
converting the case into a second nates presentation. 



SPECIAL TREATMENT OF SECOND STAGE. 



Extraction is as favorable as in the corresponding posi- 
tion of the other shoulder. 

3. Tu7iiing in the first or scapulo-puhic position of 
the right shout der. — The back of the fetus is forward, 
its head is over the left iliac fossa, its legs are in the 
right posterior part of the uterus. To turn secundum 
artem, it is obvious that the feet should be drawn over 
into the left side of the womb, while the head is moved 
toward the right, for it is only by such a maneuver that 
the evolution can be made according to the natural 
flexure of the body; and could such a movement be 
made, this position would, like the second of the same 
shoulder, be converted into a first nates position. This 
is, in fact, the method of operating, recommended by M. 
Moreau (1) ; while M. Velpeau (2) proposes to accom- 
plish the same object by converting the first into a 
second position of the right shoulder, preparatory for 
turning, — the conversion to be effected by seizing the 
shoulder and rotating the body upon its axis, causing 
the head to swing round, from left to right, anteriorly or 
posteriorly, according as it may be nearest the pubes or 
sacrum, and depositing it in the right iliac fossa. There 
can be no doubt but Moreau's method would be found 
exceedingly dilficult, in a contracted uterus, and Vel- 
peau's utterly impracticable, to say nothing of the great 
risk of rupturing the uterus by such feats of obstetric 
dexterity. The safer and, doubtless, the preferable 
method is that recommended by M. Cazeaux (3), which 

(1) Trait6 Pratique des Accouchemens, Tom. II, p. 222. 

(2) Midwifery, section on Turning. 

(3) Traite Theorique et Pratique del'Art des Accoucliemens, 
p. 717. 



SHOULDER PRESENTATION. 405 



consists in introducing the right hand supine, and, after 
raising and pushing aside the shoulder, passing it toward 
the right sacro-ihac symphysis, above which the feet are 
situated; the feet being seized are brought du^ectly 
down into the excavation, making a lateral evohition, 
that is, the feet are drawn toward the right hip, instead 
of the abdomen, of the child. This method is much 
easier of execution than any other, and no objection 
lies against it, except that the child's anterior parts may 
be directed toward the front of the pelvis; but this may 
be obviated, if not by turning the body around, by rota- 
ting the head in the pelvis, according to the advice of 
Madame Lachapelle. 

4. Turning in the first or scapido-piibic position of 
the left shoulder. — The back of the child is toward the 
pubes, its head is over the right iliac fossa, its feet are 
in the left posterior part of the womb. The left hand 
is introduced supine, raises and pushes the shoulder 
toward the right iliac fossa, and then passes up over the 
left sacro-iliac symphysis, where the feet are found, 
which are to be brought straightway into the vagina, by 
a left lateral evolution. The extraction is to be man- 
aged in the same way as in the corresponding position 
of the other shoulder. 

It has been abeady declared, that cases will now 
and then be met with in practice, in which, on account 
of the excessively contracted condition of the uterus, 
it will be found wholly impossible to deliver by turning, 
I have had three or four cases of this kind, and what is 
to be done for the relief of the woman, under such cir- 
cumstances, will now claim our attention — I say for the 
relief of the vjoman, because the child, being dead, as it 



406 SPECIAL TREATMENT OF SECOND STAGE. 



always is, when the mother is brought into such fearful 
peril, has no claim to our regard; and even though it were 
alive, the paramount claims of the mother forbid the do- 
ing anything which might increase the hazard of her 
life. It is manifest that all attempts to forcibly pass 
the hand between a powerfully contracted uterus and 
the fetus, must be extremely painful, and may cause fa- 
tal rupture of the organ ; no such attempts can, there- 
fore, ever be justifiable. The only resort is mutilation 
of the child, either by eviscerating its trunk, to enable 
the operator to extract it doubled upon itself, in imita- 
tion of the natural process of duplication, or by decapi- 
tating it, in order that the body and head may be sepa- 
rately extracted. The former operation, being the only 
one of which I have any experience, I will briefly de- 
scribe, referring the reader to other treatises, particu- 
larly to the elder Ramsbotham's "Practical Observa- 
tions," for an account of the latter. 

When this operation has become necessary, the 
shoulder is forced low in the pelvis, and the arm is usu- 
ally protruded. A large incision is to be made in the 
most dependant part of the thorax, between two of the 
ribs, by means of Smellie's scissors, conducted to the 
part by two fingers of the left hand. This incision is 
to be crossed by another, which divides one or both 
ribs, so as to make a large perforation, through which 
the hand may be introduced, to remove the contents of 
the chest. The diaphragm is next to be perforated, 
and the abdominal viscera removed. The evisceration 
being completed, a crotchet is to be passed through the 
opening made in the chest, to get hold of the inferior 
part of the child's spine, or, better still, the interior of 



SHOULDER PRESENTATION, 40^ 



its pelvis; and with this instrument, traction is made to 
bring the nates into the excavation, and eventually 
through the vulva; the remainder of the dehvery is to 
be conducted as in cases of ordinary turning. 

The inexperienced practitioner should bear in mind, 
that this operation may be sooner described than per- 
formed ; for his encouragement, he may, however, be as- 
sured that it can be safely done by patience and perse- 
verance, aided by a correct knowledge of the process 
adopted by nature, in those rare instances in which her 
unaided efforts are successful. In no cases is it more 
necessary to imitate nature than in these; for I have 
distinctly observed in practice that the child is always 
extracted, as it is sometimes expelled, doubled. 



408 PHENOMENA AND MANAGEMENT 



CHAPTER XXIII. 

PHENOMENA AND MANAGEMENT OF THE THIRD 
STAGE OF LABOR. 

The third stage of labor comprises the separation 
and expulsion of the secundines ; and while this is in 
progress, the child, that had been ushered into the 
world at the close of the second stage, is assuming the 
functions of extra-uterine hfe, and divides with the mo- 
ther the attention of the accoucheur. The most im- 
portant phenomena of the third stage, in a practical 
point of view, relate to the manner in which the placenta 
and membranes are detached and expelled. In consid- 
ering them we may speak, 1. Of the instrumentality 
employed in effecting the separation: and, 2. Of the 
mode in which they separate and escape from the organs 
of the patient. 

1. The instrument alit 2/ employed in separating the 
placenta and memhranes from the uterus. — In many 
cases of labor, there can be no doubt that the pain, 
which expels the child, detaches the placenta at the same 
time ; for it can be felt by the finger over the uterine 
orifice, immediately after the birth of the child. Where, 
however, this does not take place, and the separation 
is a distinct and special part of labor, it will be found, 
I apprehend, that tonic contraction of the uterus is the 



OF THE THIRD STAGE OF LABOR. 409 



means employed by nature to accomplish it. This is 
not the account usually given by writers, who speak of 
the return of pain (muscular contraction ), after a longer 
or shorter interval, to separate as well as expel the pla- 
centa and membranes. Dr. Dewees had juster views of 
the subject, and declares that " the tonic contraction 
almost exclusively detaches the placenta from the uter- 
ine surface, in order that it may be expelled." From 
many observations, carefully made, I deem myself justi- 
fied in concluding that when the placenta is not detach- 
ed by the last labor throe, preceding the expulsion of 
the child, it is by the agency of the tonic contraction 
alone that the uterus dissolves the connection between 
itself and the placenta. I have, many times, introduced 
my fingers up to the os uteri, passing them along the 
cord as a conductor, immediately after the birth of the 
child, without being able to reach the placenta; and I 
have repeated the examination, several times, at short 
intervals, until the placenta could be reached in this 
way, and satisfactorily ascertained it to be lying loose 
and unattached, notwithstanding pain had not been 
complained of by the patient, although frequently asked 
if she felt pain. From observations like these, it may 
be safely concluded that the placenta is detached without 
pain, viz., without muscular contraction of the uterus, 
and the only other agency that can be operative is tonic 
contraction. 

That the placenta is not detached by muscular con- 
traction might have been inferred from the nature and 
design of this mode of uterine action, independently of 
observation. It is expulsive in its tendency and aim, 
and its occurrence implies, therefore, the presence of 



410 PHENOMENA AND MANAGEMENT 



something in the uterus to be expelled. But the pla- 
centa and membranesj so long as they are attached to 
the inner surface of the organ, are in bonds of vital 
union with it, and cannot, in any sense, be reckoned as 
extraneous matters. This consideration explains, if I 
mistake not, a fact as notorious as remarkable, constantly 
occurring in cases of abortion. I allude to the prolonged 
retention of the placenta and membranes, where the 
ovum is ruptured and the fetus escapes. At the period 
of pregnancy, when these accidents usually happen, the 
connection of the fetal envelopes with the uterus is 
stronger than at the conclusion of gestation, and the 
womb is less powerfully contractile. Hence, these en- 
velopes are not so easily separated; and until they are, 
nature will make no effort to expel them. Meanwhile, 
as the separation slowly progresses, the woman is ex- 
posed to repeated attacks of hemorrhage, until it is 
completed, and expulsive contractions are aroused by the 
irritation of the detached placenta and membranes, then 
acting as a foreign body in the uterine cavity. 

But although muscular contraction is not the agency 
provided by nature to detach the placenta and mem- 
branes, it must not be supposed that this mode of ute- 
rine action is incapable of such an effect, should it be 
excited by any cause whatever. For, it is manifest 
that muscular contraction diminishes the cavity of the 
uterus, as well as tonic contraction ; and this diminution 
of its cavity, no matter how produced — nothing being 
contained in it beside the placenta and membranes — 
must cause then separation. We have an illustration of 
the truth of this remark, in cases of retention of the 
placenta from uterine inertion, that is, on account of de- 



OF THE THIRD STAGE OF LABOR, 411 



fective tonic contraction, in which the administration of 
ergot, or the introduction of the hand into the cavity 
of the womb, excites pains that both separate and expel 
the placenta. 

2. Of the manner in which the placenta and mem- 
branes are separated and expelled. — The separation be- 
gins with the placenta, and commences usually about its 
center, extending gradually toward its margin. While 
this is going on, more or less blood escapes from the de- 
nuded mouths of the uterine vessels, and, by its pres- 
sure, forms the detached portion of the placenta into a 
cup-like cavity for its reception. When the attachment 
of the margin of the placenta is broken up, the entire 
mass falls by its gravity, or is pushed by uterine con- 
tractions, to the external orifice of the womb, — its 
smooth, fetal surface being foremost. The placenta, fal- 
len or driven to the inferior part of the uterus, necessa- 
rily draws the membranes along with it, which are inver- 
ted as they are torn loose. As the placenta is expelled 
through the vagina and vulva, it becomes more cupped, 
and the membranes, as they are peeled off the inner 
surface of the uterus, continue to be inverted, so that 
when the whole is expelled, they are completely turned 
inside out and thrown over the lobulated uterine surface 
of the placenta, concealing the blood that had been ef- 
fused into the placental cup, which is now seen to be 
coagulated, upon lifting its membraneous covering. 

The separation of the placenta sometimes takes 
place differently. Its margin may be detached first; 
and if it should happen that the separation begins with 
that part of its margin which is below and near the os 
uteri, the placenta is rolled into a cylinder in the direc- 



412 PHENOMENA AND MANAGEMENT 



tion of the axis of the uterus, and its lobulated surface 
is presented to the examining finger. In this case, as 
Baudelocque remarks, its expulsion is preceded by the 
discharge of a httle, or it may be a considerable quan- 
tity, of fluid blood. No more blood may be effused 
than is perfectly normal; and yet, because it flows away, 
instead of being retained, for want of a placental cup, it 
might alarm the medical attendant, unless he satisfies 
himself of the cylindrical disposition of the placenta. 

After the expulsion of the secundines, no mechanical 
obstacle is opposed to the full exercise of the tonic con- 
traction of the uterus ; and if this be healthily exerted, 
the womb sinks into the hypogastric region of the abdo- 
men, where it can be felt by the practitioner as a hard 
globe, of considerable magnitude. The tonic contraction 
diminishes the caliber of the utero-placental vessels 
sufficiently to prevent the flow of much blood fiom their 
orifices, though it is usual for some to escape during the 
first twenty-four hours, and the lochial secretion may be 
tinged with blood for several days. 

In the management of this stage of labor (I speak 
now only of its ordinary management), the attention of 
the practitioner is, as already intimated, divided between 
the mother and new-born child ; and in considering his 
duties it will, therefore, be best to enumerate them, as 
nearly as possible, in the order in which they are com- 
monly performed. 

1. Immediately after the child is born, it is to be 
taken hold of by the practitioner and removed as far 
from the genitals of the mother, as the length of the 
cord will allow. This removal should be slowly and 
dehberately accomplished, that the cord be not jerked 



OF THE THIRD STAGE OF LABOR. 413 



or put on the stretch, and the child must be brought 
from under the cover and placed on its back or side, that 
air may have free access to it, when, if not before, it 
begins to breathe and cry. 

2. Having provided for the child, the accoucheur 
should next spread both his hands over the hypogastrium 
of the mother, either in contact with its integuments or 
with very thin covering intervening, to ascertain 
whether the uterus be properly contracted or not. If 
it be contracted, he will be able easily to feel its hard 
globe, which he may search for in vain, if it be in a state 
of relaxation. In the first case, its contraction should 
be increased, or at least maintained, by pretty firm 
pressure with the hands; in the second, its contraction 
should be excited by fiiction over the whole abdomen, 
with both hands, alternated with strong pressure. Ab- 
dominal friction and pressure wiU, according to my 
experience, seldom, if ever fail, to arouse the uterus 
fi'om its letharg}^; and the success of these valuable ex- 
pedients win be announced by the gradual gathering of 
the expanded organ into a ball under the hands, which 
is wound tighter and tighter, as the tonic contraction 
increases in power, until the globe is estabhshed. 

3. The accoucheur then turns to the child again, to 
inquire whether it can be safely severed from the mother, 
by cutting the cord, which had hitherto connected it 
with her. To decide this question, he must examine 
the state of the ckculation in the umbiHcal vessels, 
which is done by taking the cord between his thumb 
and finger, and noting the degree of pulsation that ex- 
ists in its arteries. If the pulsation be strong, the whole 
length of the cord, or as far toward its placental end as 



414 PHENOMENA AND MANAGEMENT 



it can be examined, he may conclude that the new mode 
of Hfe, which is now just beginning, is not perfectly es- 
tablished ; for when the lungs are fully inflated, and the 
new channels of circulation are freely opened, the blood 
forsakes its fetal routes, and the umbiUcal pulsation 
becomes feeble or extinct, or if it can be felt near the 
child's abdomen, it ceases at no great distance from it. 
The cord must not he divided until the ?ieto or extra- 
uterine life is satisfactorily estaUislied. It is not, how- 
ever, necessary to defer this operation until there is a 
total cessation of the umbilical pulse, under the puerile 
apprehension that the child may be feeble and sickly all 
its life, in consequence of the loss merely of the little 
blood that may be faintly circulating in the umbilical 
vessels, when the section of the cord is made. 

The division of the cord is a very simple affair; it 
is done with a pair of scissors (which should be 
sharp), after having tied a ligature very tightly around 
it, at the distance of about two fingers' breadth from 
the umbilicus. The cord should be cut half an inch be- 
yond the ligature, or far enough to prevent the liga- 
ture slipping off, after the section is made. It was 
formerly the practice to apply two ligatures, and divide 
the cord between them, for what reason, I am unable to 
conjecture, unless to guard against hemorrhage from the 
placental end of the cord, which might have been dread- 
ed when this branch of the fetal circulation was imper- 
fectly understood. It is now well known that whatever 
bleeding of this kind may occur, proceeds from the fetal 
vessels in the placenta, and cannot, of course, affect the 
mother, while, by depleting the placenta, it only makes 
its expulsion easier. The child being severed from 



OF THE THIRD STAGE OF LABOR. 416 



the mother, is dehvered to the nurse or female friend, 
who receives it in a warm blanket. 

4. The accoucheur next makes an examinatioD, to 
learn whether the placenta be detached or not ; which 
is done by taking hold of the cord with the left hand, 
and pulling it cautiously until it is straightened (not 
stretched), and the indexfinger of the right hand is 
then slid along the cord, as a conductor into the patu- 
lous genitals of the patient. If the placenta be de- 
tached, it is lying loose about the external orifice of the 
uterus, or partly in the upper portion of the widel}^ 
dilated vagina, and the finger is readily conducted to its 
smooth surface, where, also, the root of the cord is felt, 
if the placenta have been separated in the most usual 
way. If it have been roUed into a cylinder in sepa- 
rating, the finger may not reach the root of the cord, 
and will not feel the smooth, but the lobulated, surface 
of the placenta ; still it may identify it as the placenta. 
If the placenta cannot be reached in such an examina- 
tion, it may be infen^ed that it is still attached to the 
uterus. 

The conduct of the practitioner must be determined 
by the result of this exploration. If the placenta is not 
detached, the abdominal frictions and pressure should 
be renewed and diligently kept up, repeating the vaginal 
examination, from time to time, to ascertain whether or 
not the placenta can be reached by the finger. Should 
these efforts to bring the placenta within reach, by ex- 
citing uterine contractions, be unsuccessful, there will 
be ground to conclude that some unusual obstacle 
exists, requiring for its removal more than the ordinary 



416 PHENOMENA AND MANAGEMENT 



treatment J wliicli it is the object of this chapter to 
expound. 

If, on the other hand, the placenta is detached, are 
we to wait for its natural expulsion? or, if we are not 
to commit the case unreservedly to the resources of na- 
ture, how long shall we wait before we proceed to 
extract the placenta? Different rules of practice have 
been inculcated by eminent teachers, in relation to this 
part of the duties of the accoucheur; without discussing 
their merits, I shall simply state my own views and the 
practice which I have ever pursued. 

It has always appeared to me that when the pla- 
centa is detached and lying loose in the genital organs, 
there is no necessity of waiting for its expulsion by the 
contractions of the uterus. Writers, who attach im- 
portance to the recurrence of the uterine contractions 
for this purpose, do not discriminate, as they ought, be- 
tween the tonic and muscular contractions of the partu- 
rient organ, and assign to each its appropriate office. 
Their anxiety for the return of pains is evidently predi- 
cated upon the supposition that the patient is in an inse- 
secure and perilous state without them ; for their ab- 
sence, it is imagined, is indicative of a relaxed condition 
of the womb, which might, at any moment, give rise to 
hemorrhage. With such views, it is no wonder that the 
artificial removal of the secundines, in the absence of 
uterine contraction, is condemned by them as rash and 
hazardous. But it has been shown that muscular con- 
traction of the uterus has nothing to do, either with 
the separation of the placenta or the prevention of 
hemorrhage; these are the work of the tonic contrac- 
tions, and the muscular is alone concerned with the work 



I 



OF THE THIRD STAGE OF LABOR. 417 



of expulsion. The tonic contraction may exist in a 
high degree, as we can easily satisfy ourselves by the 
tests that have been explained, and yet, in this third 
stage of labor the uterus may be disposed to rest from 
its more active expulsive efforts, and tolerate, for a long 
time, the presence of the secundines in its cavity. It 
is wearied _by the exertions it made, in the previous 
stages of labor, and withal it possesses less muscular 
force, as we have seen in a former chapter. 

In this jaded and crippled condition of the uterus, 
if the placenta be allowed to remain in its cavity, there 
may be no return of expulsive efforts for hours or days; 
and meanwhile the secundines' begin to decompose and 
emit an offensive odor; the genital surfaces become sore 
and heated, and the uterine orifice is contracted; so that 
when driven at last to extract the placenta, the practi- 
tioner encounters no little difficulty, and the patient suf- 
fers greatly on account of the procrastination. 

If, then, the only good that can result from the re- 
turn of laborpains is the expulsion of the placenta, ly- 
ing loose and waiting to be expelled, and nothing but 
j evil is to be expected should it be retained long, I can- 
' not but regard it as culpable timidity or neghgence in 
the practitioner, to call upon Hercules when he might 
help himself; for it is within his power easily and safely 
to extract the placenta, whether there be pains or not. 
I For my own part, I am ready to avow that I seldom 
wait for pains, or inquire of the patient whether she 
I feels them or not, — my only solicitude being to have 
I the womb well contracted, and the placenta naturally 
\ separated. These conditions existing, I proceed, with- 
/ out delay, to extract the placenta, like a good miller 
27 



418 PHENOMENA AND MANAGEMENT 



(pardon the pun), when its turn to be served comes, 
that is, after the matters, akeady specified as entitled to 
precedence, have been dispatched. 

The extraction of the placenta and membranes is, 
usually, a simple affair. In its performance it is, how- 
ever, proper to observe certain precautions which I pro- 
ceed to suggest. The extraction is effected by tractions 
upon the cord, made by taking hold of it, near its cut 
extremity, with one hand, entwining it about the fingers 
to make the hold more secure, and seizing it between 
the thumb and fingers of the other hand, except the in- 
dex, near the vulva, — the index being at hberty that it 
may be introduced into the vagina, to note the progress 
of extraction. Traction is to be made, in the first place, 
downward and backward, until the placenta is drawn 
into the vagina, and this direction may be given to the 
force by the hand next the vulva. Should there be any 
difficulty in causing the placenta to move in that direc- 
tion, it may be overcome by pressing upon it near the 
root of the cord, with the points of two fingers, or by 
introducing two fingers deeply into the vagina, to press 
the cord toward the hollow of the sacrum, as far as pos- 
sible, and holding them there as a pulley to give the de- 
sired direction to the force exerted by the other hand. 
When the placenta is brought fully into the vagina, 
traction is to be made upward and forward, in the direc- 
tion of the axis of the vulvar space, when the placenta 
is readily brought through the external organ, at which 
time some pain is commonly complained of, and the dia- 
phragm and abdominal muscles are excited to expulsive 
efforts. 



OF THE THIRD STAGE OF LABOR. 419 



When the placenta is extracted in this manner, it is 
doubled upon itself, and the membranes are inverted 
and turned over tov^^ard its uterine surface, as in cases 
of natural expulsion. The membranes are, however, 
hable to be broken off, and one or more fragments of 
them may be left in the uterus. No serious conse- 
quences need be apprehended fi'om this accident ; but the 
retained membranes may become the nucleus, around 
which blood coagulates, to form a mass of considerable 
size and firmness ; and this being expelled, in the course 
of a few days, may be mistaken for a part of the pla- 
centa, and reflect discredit upon the practitioner. Or, 
this coagulum of blood may be supposed to be the 
uterus itself, prolapsed or inverted, or a polypus or 
other tumor, and give rise to great and unnecessary 
alarm. Instances of these mistakes and groundless 
alarms, have fallen under my observation. I remember 
one case, in which the medical gentleman who had de- 
livered the patient, came for me in person, to go with 
him to her house, two days afterward ; teUing me that 
the patient had discovered something unusual about 
her, and that he found, on examination, a tumor of some 
kind, in the vagina, which he feared was the womb, dis- 
placed. Before coming for me, he had pushed up the 
supposed tumor, and inserted a tampon to hold it up. 
On removing the tampon, it was soon discovered that the 
tumor had no connection, whatever, with the parts; and 
upon extracting it, its true nature was disclosed by 
pulling it to pieces, and bringing to hght its membra- 
neous substratum. 

To prevent the laceration of the membranes, and the 
leaving any portion of them behind, it is a good rule of 



420 PHENOMENA AND MANAGEMENT 



practice to draw the placenta very slowly through the 
vulva ; as it comes forth^ take hold of it with the hand 
and twist it several times, in order that the membranes, 
by being twisted together, may be made stronger and 
less liable to break. The placenta ought, moreover, to 
be slowly tvithdrawn from the vulva, after it is disen- 
gaged, and the finger of the other hand should be passed 
into the vagina, to help along the tail of membranes, 
and to remove any fi-agments that might otherwise re- 
main. He only can, to use a popular and expressive 
word, be said to have cleared his patient, who is careful 
to attend to all of these minutiiB, which may appear 
finical to some. 

5. The patient having been cleared, the next duty 
of the accoucheur is, to apply the binder for the purpose 
of giving support to the relaxed muscles and integu- 
ments of the abdomen, and, by its pressure upon the 
uterus, keeping up a due degree of tonic contraction, 
on which her safety so materially depends. A towel, 
long enough to go around the hips and wide enough to 
cover the abdomen, from the pubes to the cartilages of 
the ribs, or a piece of cloth of equal dimensions, makes 
a good binder, which has the advantage of being always 
at hand. It should be applied next the skin, which can 
be done under the bedclothes, by pushing one end of it, 
rolled like a bandage, under the back and hips, and un- 
rolling it as it is brought forward over the abdomen, to 
be pinned opposite the side. It should be drawn quite 
tight over the hypogastrium, and slacker over the upper 
region of the abdomen ; and if it be desirable to make 
greater pressure upon the hypogastrium, another towel 
folded can be placed under it as a compress. The only 



OF THE THIRD STAGE OF LABOR. 421 



objection to this extemporaneous bandage is, its liabiKty 
to slip above the hips, which may be obviated by a strip 
of cloth passing between the thighs, and pinned to it 
before and behind, in the manner of the T bandage. 

The proper apphcation of the binder I consider a 
point of sufficient importance to demand my personal 
attention, in every case. I always apply it myself, un- 
less the patient have a nm^se, in whose intelligence and 
careMness I have confidence. To justify this solicitude 
concerning a matter regarded as trivial by some, it may 
not be amiss to mention another accident, quite as 
alarming though not so dangerous as uterine hemorr- 
hage, which the binder is calculated to prevent. I al- 
lude to faintness accompanied by sinking, bordering on 
collapse, which occasionally supervenes, shortly after the 
parturition. There may be other causes for this state, 
but I am persuaded that in many instances, it is owing 
to the sudden removal of the stimulus of distention, by 
the emptying of the gravid uterus, which acts in the 
same manner as drawing off the fluid of ascites, but 
more deleteriously, on account of the shock infhcted 
upon the nervous system, by the sufferings and efforts 
inseparable from childbirth. This persuasion rests upon 
observation in the lying-in chamber ; for I have seen pa- 
tients, prostrate and unable to speak above a whisper, 
with feeble, faltering pulse, cold extremities, and other 
marks of great depression, speedily aroused to greater 
animation by the careful application of a tight abdominal 
bandage, aided by a hypogastric compress. 

6. Inasmuch as nothing is so essential to a woman, 
recently dehvered, as rest and freedom from annoyance 
of every kind, at least until her exhausted powers are 



422 phenojMena and management of third stage. 



recruited, it is a good general rule to direct an anodyne, 
before leaving her. The anodyne must necessarily be 
some of the preparations of opium ; two teaspoonsful of 
paregoric, thirty or forty drops of laudanum, or half a 
grain of morphia, may be given, according to circum- 
stances. I am aware that this practice has been con- 
demned, on account of the supposed danger of its inter- 
fering with the proper contraction of the uterus ; but 
this objection is, I apprehend, altogether theoretical, for 
I have have never seen anything to countenance it» 



ASPHYXIA NEONATORUM. 423 



CHAPTER XXIV. 

ASPHYXIA NEONATORUM.— MORBID RETENTION OF 
THE PLACENTA.— UTERINE HEMORRHAGE, BE- 
FORE AND AFTER THE REMOVAL OF THE SE- 
CUNDINES. 

It has been already stated, that the duties and 
responsibilities of the obstetrician thicken in the thu-d 
act of the drama of labor, and it may be added, not un- 
frequently great vigilance, on his part, is required to 
avert a tragical termination, either in regard to the 
mother or child. Pursuing the method akeady indica- 
ted, namely, enumerating and explaining his duties, in 
the order in which they most usually arise, we may 
consider the asphyxia of new-born infants among the 
first of the accidents demanding his attention. 

The condition of an infant born asphyxiated, is 
analagous to that of adults after strangulation, or the 
resph'ation of gases unfriendly to life. It is, in fact, 
brought into this condition by the operation of the va- 
rious causes that may arrest its umbilical circulation, or 
hinder the oxygenation of its blood, in the placenta. 
The circulation of blood through the umbilical vessels 
is hable to be arrested by compression of the cord, 
where it prolapses before the presenting part of the 
child, especially the head; and, also while the head is 
detained in the pelvis, in nates presentations. The 



424 TREATMENT OF THE THIRD STAGE. 



oxygenation of the fetal blood, though it may flow into 
the placenta, is prevented by an inadequate supply of 
the mother's blood, in the maternal portion of the pla- 
centa, resulting from the long continuance of strong con- 
tractions of the uterus, after the escape of a portion, 
much more, of the whole, of the liquor amnii, and espe- 
cially from the almost uninterrupted, as well as power- 
ful, contractions induced by the administration of ergot. 
The bowstring is not more murderous than ergotic con- 
tractions of the womb. 

Whether the fetal or maternal blood be prevented 
from circulating through the placenta, the effects upon 
the child are the same; its blood not being vitalized in 
the placenta, soon ceases to flow in that direction, and 
is sent, in unusual quantity, to its internal organs, par- 
ticularly the brain; because such large currents as had 
been hitherto sent to the placenta, being suddenly stop- 
ped, the descending aorta cannot receive and distribute 
as much blood as before, and consequently more blood is 
thrown into the carotid and subclavian arteries. While 
this derangement of the balance of the fetal circulation 
is going on, the action of the heart grows feebler, for the 
want of duly oxygenated blood, until it altogether 
ceases, — never to be aroused again, unless the child be 
born in time to be recuscitated. 

It is not difficult to recognize the existence of as- 
phyxia in the new-born child. Its insensibility, immo- 
bility, absence of respiration, and of any effort to estab- 
hsh it, together with the cessation, usually, of pulsation 
in the cord, and the heart having ceased to beat, — in 
short, all the tokens of apparent death, — too plainly in- 
dicate it to allow mistake. To the signs just enumera- 



ASPHYXIA NEONATORUM. 425 



ted, should be added, lividity and tumefaction of the 
surface of the body, especially of the face. 

Asphyxia, produced by the causes that have been 
mentioned, and accompanied by the signs that have been 
described, may be called simple^ to distinguish it from 
another form of the malady, not unfrequently met with 
in practice, which I propose to term apoplectic asphyxia, 
in which there is a deeper congestion of the brain, or, it 
may be, a still more serious lesion of this organ. This 
is treated of, by most writers, as apoplexy of new-born 
children ; but as it is generally associated with asphyxia, 
and differs from it only in degree, there is no necessity 
of separating them. Apoplectic asphyxia, although it 
may result from the same causes as the simple, is, I 
apprehend, most usually induced by severe and long- 
continued compression of the head, from difficult and 
instrumental deliveries, — whereby the blood is forced 
from the surface of the head to the brain, by pressure 
of the jugular veins, in face presentations, or by com- 
pression of the inferior parts of the body, in nates pre- 
sentations, particularly where the feet are foremost, in 
consequence of which the blood is determined to the 
brain, because it is excluded from the lower parts. 

Apoplectic asphyxia is accompanied with the same 
insensibihty, immobihty, and absence of respiration that 
attend simple asphyxia ; but the heart may continue to 
beat, and the umbilical arteries to pulsate, and there is 
greater lividity and swelling of the face, the eyes being 
prominent and injected with blood, and the pupils di- 
lated. In both forms of the disease, when the means of 
resuscitation have been ineffectually applied, the heart 
and large vessels will be found gorged with black blood, 



426 TREATMENT OF THE THIRD STAGE. 



and cerebral congestion will be discovered : but in the 
apoplectic variety, there may be effiision of reddish 
serum upon the surface and within the ventricles of the 
brain, or extravasation of blood, coagulating into a layer, 
of considerable thickness, upon the surface of the cere- 
bral hemispheres. 

The treatment of asphyxia neonatorum may be di- 
vided into, 1. That which is proper in the simple variety 
of the malady: and 2. That which is recognized in the 
apoplectic form. Simple asphyxia is to be remedied by 
the employment of all the means calculated to put the 
respiratory apparatus in motion. Among these, one of 
the most powerful is, sprinkling the surf ace^ particularly 
the face and chest, with cold ivater. For this purpose, 
the fingers should be repeatedly dipped in cold water, 
and shower the fluid, with considerable force, upon the 
parts indicated. The practitioner ought to be careful 
not to have the fingers too wet, so as to drench and 
chill the child, and after each application, or, at all 
events, now and then, the surface should be wiped dry 
and well rubbed. The skin is thus rendered more sen- 
sitive, and the probability is greater that the resphatory 
nerves will be excited through its medium. Desormeaux 
and P. Dubois recommend, as an excitant of respiration, 
which has more frequently succeeded in their hands than 
all others, a sort of douche upon the parietes of the 
thorax, made by fiUing the mouth with eau-de-vie 
(brandy), and spurting it forcibly upon the breast. It 
is, they say, rarely necessary to repeat this many times : 
it soon causes a convulsive contraction of the inspiratory 
muscles, blood and air penetrate the lungs, respiration 
is established, in an irregular manner at first, being 



ASPHYXIA NEONATORUM. 427 



feeble and convulsive, but it speedily becomes stronger 
and more regular (1). I have no experience of this, 
but it evidently acts on the same principle, and its 
effects are the same, as sprinkling with cold water. 

With the same view, frictions should be made on 
various parts of the body, — upon the extremities, ac- 
companied by smart slapping of the palms of the hands 
and soles of the feet, along the spine, upon the temples, 
etc. Smellie seems to have had great faith in flagella- 
tion, as a means of resuscitating still-born children. In 
his "Treatise on the Theory and Practice of Midwifery," 
he observes, "Whatever augments the circulating force, 
promotes respiration; and as this increases, the circula- 
tion grows stronger, so that they mutually assist each 
other. In order to promote the one and the other, the 
child is kept warm, moved, shaken, wJiipioed] the head, 
temples, and breast rubbed with spirits; garlic^ onion, or 
mustard applied to the mouth and nose," etc. Speak- 
ing, in his "Collection of Cases," of the different means 
had recourse to, to resuscitate a still-born child, after deli- 
very by turning, in a difficult case of shoulder presenta- 
tion, he says, "That which had the greatest effect, was 
whipping his little breech, from time to time, for which 
I ask pardon of my old friend and preceptor. Dr. Nidi- 
olUr The mucous membranes may also be irritated, as, 
for example, by holding camphorated spirits, hartshorn, 
etc., to the nose, and a httle camphorated or simple spi- 
rits may be put in the mouth. Of blowing the fumes 
of burnt paper into the anus, recommended by Baude- 
locque and others, I have no experience. 

(1) Dictiomiaire de Medecine, article Nouveau-ne. 



428 TREATMENT OF THE THIRD STAGE. 



The warm bath is advised by almost all writers, but 
I have seldom used it; and the little I have seen of it, 
has not impressed me very favorably. Should the 
means already recommended fail to arouse the child, 
the next recourse is, artificial inflation of the lungs ; 
and if this does not succeed, nothing more can be done. 
To inflate the lungs, I have been in the habit of apply- 
ing my mouth to the child's, after having made a deep 
inspiration, and expiring the air, pretty forcibly, taking 
the precaution to close its nostrils with the fingers of 
one hand, while those of the other press moderately 
upon the trachea, to close the esophagus, to insure its 
passage into the lungs. Successful inflation is indicated 
by the rising of its chest, when the blowing is to be in- 
termitted and the air forced out, by pressure with the 
hand upon the chest and abdomen; the blowing is then 
to be repeated, alternated with pressure, until respira- 
tion is established, or we are convinced of the hopeless- 
ness of our efforts. These efforts must not, however, 
be relinquished until they have been fully and fairly 
tried, — for I have known them succeed, after the lapse 
of half an hour of disappointment. 

In the apoplectic form of asphyxia, the great rem- 
edy is Uoodletting, which must be promptly practiced 
by cutting the umbilical cord, when, if its circulation be 
active, blood immediately spouts from its arteries. We 
have been directed to receive the blood in a vessel or 
upon a diaper, that we may estimate the quantity sub- 
tracted. But I take no such precautions; and instead of 
looking nervously at the blood, look at the child's coun- 
tenance, watching the chasing away of its purple hue 
by the rosy tints of health; and when its complexion is 



ASPHYXIA NEONATORUM. 429 



goodj I arrest the bleeding. While the blood is flowing, 
the child usually begins to breathe, at first with a sort 
of convulsive struggle, but presently it breathes deeply, 
and announces, by its cries, that it has escaped the 
danger that menaced it at the portal of life. If the 
umbilical pulsation be faint or extinct, blood cannot be 
procured so freely from the cord ; when the bleeding 
should be promoted by stroking it and immersing the 
child, to its naval, in warm water, made more stimulating 
by the addition of salt or mustard. If blood cannot be 
obtained in this way, a leech should be applied behind 
one or both ears. If bloodletting fail to resuscitate, the 
other means, already recommended in simple asphyxia, 
should be tried. 

I have said nothing of bloodletting, in the treatment 
of simple asphyxia; cases of this kind do, nevertheless, 
occur, in which it is not only proper but highly benefi- 
cial. Whenever the child is decidedly plethoric and 
congested, although the congestion may not reach the 
hight of apoplexy, it is useful and salutary to detract 
blood from the cord. Nay, ample experience justifies 
me in saying, that, when even simple asphyxia does not 
exist, if the child be plethoric and discolored, showing 
that it has suffered from the manner in which it has 
been ushered into the world, it will be benefited by 
losing a little blood, and secured, as I have reason to 
believe, from the convulsive affections, inflammations, 
and hemorrhages, to which it would be otherwise ob- 
noxious. 



430 TREATMENT OF THE THIRD STAGE. 



Morhid retention of the placenta. 
In the preceding chapter, the means of promoting 
uterine contraction, to insure a prompt separation of the 
placenta, were pointed out. These means are so effica- 
cious, and, indeed, the tendency of unaided uterine 
action to detach the placenta is so strong, that where it 
is not speedily detached, there is reason to fear the 
existence of some unusual obstacle. The practitioner 
ought, nevertheless, to persevere in the assiduous use 
of his abdominal frictions and pressure, for at least an 
hour, before he despairs of their success. If, at the ex- 
piration of this time, he is still unable to feel the pla- 
centa or any part of it, in an ordinary vaginal examina- 
tion, he may conclude that morlid retention exists, and 
proceed to inquire into its nature. In such a case, it 
will be found that the placenta is retained by one or the 
other of the following causes, viz., atony of the uterus^ 
morhid adhesion of the placenta^ or irregular contraction 
of the uterus^ which, as they require a difference of treat- 
ment, must be separately considered. 

Atony of the uterus as a cause of retention,—- This 
may be ascertained to exist by the large size, and flabby, 
amorphous feel, of the uterus, examined through the 
parietes of the abdomen. There is, likewise, an entire 
absence of pains, and the placenta cannot be reached by 
the finger, passed along the cord made moderately tense. 
If the placenta be partially detached, there is, necessa- 
rily or, at least, commonly, uterine hemorrhage ; but if it 
retain its connection with the uterus, no blood is effused, 
and the woman is in no immediate danger. 

Undue protraction of the previous stages of labor, 



MORBID RETENTION OF THE PLACENTA. 431 



is, according to my observatioiij the most common cause 
of uterine atony, in the third stage, the parturient 
power being so exhausted as to be inadequate to fur- 
ther vigorous exertion. But it may happen that too 
prompt expulsion of the child will leave the uterus in 
this atonic condition, because the organ is, then, as Bau- 
delocque expresses it (1), taken by surprise and is so 
stupefied as to have its contractile faculties suspended. 
On the same principle, the extraction of the child, by 
manual or instrumental force, in the absence of pains, 
may be followed by atony of the uterus. 

When uterine hemorrhage attends retention, from 
this cause, all are agreed as to the imperative necessity 
of extracting the placenta, with suitable precautions to 
insure a due degree of tonic contraction of the uterus. 
But if there be no hemorrhage, there is not the same 
accord, but discord rather, among wters and practition- 
ers as to the proper course of procedure. Some main- 
tain that after a hmited and specific time, the accouch- 
eur ought to interpose and terminate the suspense of 
the patient, while others deprecate interference merely 
on account of the lapse of any time. To the latter class 
belonged our celebrated countryman. Dr. Dewees, who, 
for so long a period, ruled om^ obstetrical realm with an 
absolute sway. "I have always objected to making 
•^time ' the criterion for action in midwifery," says Dr. 
Dewees, in discussing the subject now under considera- 
tion; and on the next page he declares, "When this 
state of things presents itself," (viz., retention from 
want of tonic power ) " all attempts to dehver the pla- 
centa must be forborne, until we have, by properly in- 

(1) Par. 232. 



432 .TREATMENT OF THE THIRD STAGE. 



stituted frictions over the region of the uterus, obhged 
it to contract and harden itself under the hand " (1). 
But what if the uterus wont be " obhged " to harden, 
and obstinately remains flaccid ? We have been rub- 
bing it for an hour, according to our directions, and still 
it is as incoherent as dough ; how much longer shall we 
rub ? Quousque tandum abutere, pontifex obstetricie, 
patientia nostra ? So unfruitful have occasionally been 
all my efforts of this kind. There is a more direct and 
powerful means of exciting the uterus to contraction ; 
Avhy not resort to it now, without relying any longer 
upon that which has baffled us for the space of an hour? 
The more powerful uterine excitant, to which refer- 
ence is made in the preceding paragraph, is, the intro- 
duction of the hand into the flaccid cavity, to arouse its 
torpid parietes, to action, and to withdraw the placenta. 
My own " fixed " rule of practice, in this case as well as 
in retention from the other causes mentioned, is, to have 
recourse to this manipulation, in an hour after the birth 
of the child, it being understood, of course, that all other 
means have been diligently but vainly tried within the 
hour. The passage of the hand, well lubricated with 
oil or lard, along a track so recently traversed by the 
child and yet patulous, from atony, is neither a painfiil 
nor difficult operation. In performing it, the patient 
must be placed on her side, or, if she lie on her back 
(which I commonly prefer), her pelvis must be near the 
edge of the bed, with the perineum slightly projecting, 
her feet being supported on chairs, or the laps of assis- 

(1) Midwifery, Chapter 32, of the Assisted Delivery of the 
Placenta. 



MORBID RETENTION OF THE PLACENTA. 433 



tants, because the Lead having to follow the axis of the 
excavation, the arm must necessarily be greatly depres- 
sed. The practitioner should pull off his coat and roll 
up the shirtsleeve of the arm, usually the right one, 
which is to be used in operating: the latter part of the 
preparation ought not to be made in view of the patient, 
or, indeed, of the bystanders. It can be done, as well, 
under the covering which protects the patient against 
unnecessary exposure and him from prying observation. 
The preliminaries being settled, the accoucheur takes 
the cord in his left hand, twisting it about the fingers 
to get a secure hold of it, and draws upon it until it is 
straightened or rendered a httle tense. The cord is to 
be thus held, as a guide to conduct to the placenta the 
other hand, which, formed into a cone, by pressing the 
fingers closely together and flexing the thumb upon the 
palm, is now introduced in the direction of the axis of 
the inferior strait, viz., upward and hachward, until it 
is fahiy lodged in the vagina. It next enters the ute- 
rus ; and, in this part of its introduction, it moves up- 
ward and forward, in the direction of the axis of the 
superior strait, while an assistant presses on the abdo- 
men to steady the uterus. Conducted by the cord, the 
hand arrives at the placenta, upon which pressure is to 
be made with the knuckles, while counter pressure is 
kept up by the other hand (now no longer needed to 
hold the cord), through the walls of the abdomen. The 
hand is, also, moved about in the uterine cavity, and 
brought in contact with other points of its parietes, to 
stimulate them to contraction. It happens sometimes 
that when contractions cannot be provoked by these 
assaults of the hand, they are evoked by feigning a re- 
28 



434 TREATMENT OF THE THIRD STAGE. 



treat in partially withdrawing the hand. Cases occa- 
sionally occur, in which neither of these maneuvers is 
successful, and then I have not scrupled to make a cau- 
tious separation of the placenta, by a finger insinuated 
between it and the uterus, which will hardly fail to 
excite contraction. When contraction takes place, it 
may separate the placenta, or complete the separation 
the practitioner had commenced, and the hand may now 
be withdrawn, bringing the placenta along with it. If 
the placenta be separated, partially or wholly, the hand 
must never be withdrawn until the uterus is felt to be 
in a state of vigorous contraction, for the patient would 
be exposed to the risk of hemorrhage from the exposed 
orifices of the utero-placental vessels. 

I know that the manual extraction of the placenta, 
under the circumstances described, in an hour after the 
termination of the second stage, has the appearance of 
a cruel operation, uncalled for by the actual condition of 
the patient. She is suffering no pain, is in no immedi- 
ate danger, and if let alone, might do well, uterilie con- 
traction, after the lapse of a longer time, coming on and 
finishing its work, with less pain than is inflicted by ar- 
tificial delivery. The arguments for delay are specious, 
and apt to captivate the timid or too sensitive practi- 
tioner. The reasons which justify the more decisive 
course I have recommended ought, therefore, to be set 
forth so strongly, if possible, as to induce its general 
adoption. Let it be remembered, then, that the pla- 
centa cannot be allowed to remain in the uterus, without 
the imminent risk of alarming hemorrhage, which may 
occur at any moment, and destroy the patient before the 
practitioner can come to her rescue. Her condition is, 



MORBID RETENTION OF THE PLACENTA. 435 



therefore, in this respect, so perilous, that the medical 
attendant would hardly be excusable in leaving the 
house, unless, indeed, his residence be very near, and 
even then he may be out of the way when an urgent 
message is sent to recall him. The practitioner is conse- 
quently fettered, and the patient is anxious about her 
situation. Supposing that she escapes hemorrhage, she 
is liable to offensive discharges from the genitals, pro- 
duced by putrefaction of the placenta — discharges so 
offensive as to infect the chamber, though spacious, with 
thek odor, and taint even the adjoining apartments, — 
and then constitutional symptoms, of the most alarming 
kind, may supervene : " purgings, vomitings, sweatings, 
a pulse of one hundred and forty, a cheek of typhoid 
tint, and a brown tongue." 

The latter part of this sketch is taken from an au- 
thor, partly in his own words, who^is by no means as 
decided in his determination to remove the placenta as 
some others; and who speaks of leaving this mass in the 
uterus with more complacency than is, I think, allowa- 
ble, because he had "noted more than one case, in ivliich 
the 'placenta had remained a long time in the uterus^ 
without a single conspicuous symptom of irritation he- 
coming manifest!' Dr. Blundell, the author referred to 
(1), seems to have experimented a good deal in this 
way, and that apparently from the strong repugnance he 
manifests, everywhere and in every variety of expres- 
sion, in his lectures, against the introduction of the 
hand into the uterus, which he never recommends, but 



(1) Lectures on the Principles and Practice of Midwifery, edi- 
ted by Charles Severns, M. D., Lecture XXX. 



436 TREATMENT OF THE THIRD STAGE. 



in connection with the risk incurred by it, when there 
is any difficulty in the operation, of hruising^ and tear- 
ing the parts, and the consolatory prospect of inflamma- 
tion^ sloughing^ and death, as its result. To this sketch 
of the consequences, lil^ely to arise from leaving the 
placenta in the uterus, already sufficiently gloomy, I will 
only add that, should it become necessary to remove the 
placenta, at a period somewhat remote from the birth of 
the child, the difficulty of the operation is greatly en- 
hanced, and there may, then, be real danger, while the 
patient must necessaiily suffer great pain, on account of 
the soreness and swelling of the parts. 

These considerations gave fixity to the rule which I 
early adopted for the government of my practice, in 
these cases, namely, the rule to deliver the placenta man- 
ually at the expiration of an hour from the close of the 
second stage. I have had no reason to repent my adhe- 
rence to the rule ; no uteruses have been torn or 
bruised, or destroyed by inflammation and sloughing 
and never having, in a single instance, allowed the pla- 
centa to abide in the uterus, I have never, in my own 
cases, snuffed the intolerable stench of its putrescence. 
Is it necessary to fortify myself with authority? Hear 
what Burns says: "We ought never to leave the bed- 
room, until the placenta be expelled; if it be not exclu- 
ded in an hour after dehvery, we ought to extract it 

I have said nothing concerning ergot, which is re- 
commended by some, or the various ,other deohstruents. 



(1) Principles of Midwifery, Philadelphia edition, 1823, vol. I, 
p. 375. 



■ 



MORBID RETENTION OF THE PLACENTA. 437 



as they are called by Dr. Blundell, who discourses at 
some length in their favor as remedies for retained pla- 
centa. Among these are, injections of senna and salts 
into the rectum, coughing, sneezing, blowing on the back 
of the hand (why deviate from a more ancient direction, 
to blow into a bottle?), but above all, r etching Sj provo- 
ked by tickling the throat with a feather. I have no 
experience with any of these things, because I regard 
them as trifling and uncertain, and know that my hand 
will not forget her cunning. I beg that the reader will 
not infer, from my commendation of the hand, that its 
introduction into the uterus is an every day feat with 
me. Far from it. According to my experience, there 
wiU seldom be occasion for it, on account of atony, if 
the previous parts of labor have been properly managed. 

Retention from morbid adhesion. 

This obstacle to the natural exclusion of the pla- 
centa, is occasionally met with in practice, and is more 
alarming than simple atony, because, according to my 
observation, it is more apt to be accompanied by he- 
morrhage, owing, as we may suppose, to all parts of the 
mass not being equally firmly adherent, and the separa- 
tion of the less adherent portion, exposing the mouths 
of bleeding vessels. The existence of morbid adhesion 
of the placenta may be suspected when the uterus feels 
firmly contracted, and the placenta is, notwithstanding, 
so high as to be beyond the reach of the finger: but it 
can only be certainl^^ detected by the hand, carried into 
the cavity of the womb. 

AYhen morbid adhesion of the placenta is suspected, 
the means alreadv directed to excite the uterus to more 



438 TREATMENT OF THE THIRD STAGE. 



powerful contraction^ should be diligently employed for 
an hour (unless hemorrhage appear, and then no delay 
is proper); and if these do not answer, we must proceed 
to its manual extraction. Baudelocque (1), and after 
him, our celebrated countryman, Dr. Dewees (2), in- 
culcated the practice of applying force to the placenta, 
by means of the cord, for the purpose of disrupturing 
its attachments and bringing it away. In order to the 
success of this method, they tell us, that the force must 
be directed in such a manner as to act perpendicularly 
to the surface of the placenta; in order to which, again, 
it must be ascertained to what part of the uterus the 
placenta is adherent, and then, by arranging a couple of 
fingers in the vagina, as a pulley for the cord to be 
drawn over, the required direction can be given to the 
force. I have no experience of this maneuver, having 
always regarded tractions upon the cord, in cases of re- 
tained placenta, no matter from what causes, as unsafe, 
on account of the danger of inverting the uterus. It 
was not, therefore, without surprise, that I discovered, 
that a late and generally judicious writer. Dr. Robert 
Lee (3), recommends these tractions, as a part of the 
ordinary management of the placenta. Discoursing of 
the treatment of natural labor, he says, "When a pain is 
felt, slight traction, in the direction of the axis of the 
brim of the pelvis downward and backward, should be 

(1) L'Art des Accoucliemens, chapter 5, section 5. Des ob- 
stacles qui provienuent des adherences centre nature du placenta, 
et de ce qu'il convient de faire en pareil cas. 

(2) Midwifery, chapter 32. 

(3) Lectures on the Theory and Practice of Midwifery, Phila- 
delphia edition, 1844, page 222. 



MORBID RETENTION OF THE PLACENTA. 439 



made upon the cord/' and with what object? why, "to 
promote the separation of the placenta from the uterus." 
"By compressing and squeezing the fundus uteri," he con- 
tinues, "and gently pulling from time to time, on the cord, 
the placenta usually descends, and passes through the os 
uteri into the vagina, in the course of a quarter of an hour, 
or twenty minutes, or half an hour after the birth of the 
child." "More anxiety," he adds, "is often felt by us 
during this period, than during the whole of the previous 
stages of the labor, and not without good reason." Not 
without good reason, I would say, certainly; for, were I 
to imitate Dr. Lee's practice, in this particular, I should, 
undoubtedly, feel anxious, instead of being composed, as 
I usually am, by the confident expectation that the 
uterus can be excited to detach the placenta, and 
bring it within easy reach. Even in ^dew of the possi- 
bility of being disappointed in this expectation, I am 
not dismayed, for I remember my hand. 

To return from this digression. The safest and most 
rehable treatment of morbid adhesion of the placenta, 
consists in the introduction of the hand, in the manner 
and with the precautions already described; and when it 
reaches the placenta, endeavoring to excite the uterus 
to throw it off, by pressing on its surface, or, as Burns 
directs, by gently rubbing, or as it were, pinching it up 
between the fingers and thumb. Should these efforts 
fail, and this has happened in my hands, we may be 
under the necessity, contrary to the prohibition of this 
high authority, of breaking up the adhesion with the 
finger, insinuated between the placenta and uterus. 
The operation is to be executed as rapidly as is consis- 
tent with its proper performance, for, as the placenta is 



440 TREATMENT OF THE THIRD STAGE. 



being detached, the mouths of the uterine vessels, run- 
ning to it, are unstopped, and blood is felt trickling, or, 
it may be, streaming down the arm. When the placenta 
is separated, it is to be abstracted with the cooperation 
of uterine contraction. 

Retention from irregular contraction of the uterus. 

Irregular contraction of the womb is most apt to 
ensue after unusual prolongation of the previous stages 
of labor, more especially where the membranes are rup- 
tured prematurely, and the liquor amnii flows away 
entirely, before the child engages in the os uteri. The 
tendency to unequal and irregular contraction, under 
such circumstances, has been noticed in the former part 
of this treatise, and the chosen seat of it has, also, been 
pointed out. That seat, it will be remembered, is the 
upper part of the neck, the cervico-uterine orifice. 
Whether contraction exists, at this part, prior to the 
expulsion of the child, hindering its escape, or takes 
place immediately after its birth, the uterus, it is evi- 
dent, will be divided into two cavities, — a superior 
cavity, that of the body, and an inferior cavity, that of 
the neck, — and the entke organ will resemble an hour- 
glass, only its superior compartment is much the largest. 
From this similitude, the contraction itself is called the 
hour-glass contraction of the womb. 

The above is substantially the description given of 
this morbid state of the uterus, by Baudelocque, in section 
seven, of the chapter cited a little while ago, and most 
subsequent writers have confirmed its accuracy. It 
accords certainly with my own observation; but recently 
it has been confidently asserted that this kind of irre- 



MORBID RETENTION OF THE PLACENTA. 441 



gular contraction is exceedingly rare, compared with 
others, and it has even been denied that it ever occurs 
in practice. The first affirmation is made by Dr. Francis 
Eamsbotham(l), who says, " We hear much of hour-glass 
contraction of the uterus, but my belief is, that there is 
(are) no rarer cases in midwifery than the real and true 
hour-glass contraction, such as I have described it." A 
little further on, he observes that he does not recollect 
to have met with more than three or four cases that 
perfectly agreed with his idea of the true hour-glass 
contraction. And what is his idea of the contraction in 
question? That is sufficiently explained in the text 
and illustrated by a figure. No. 137. It is contraction of 
the central fibers of the lody^ dividing the uterus into 
equal compartments. Dr. Eamsbotham may be es- 
teemed fortunate (if it be good fortune to meet with 
varieties), in meeting with three or four such cases, for I 
avow that I have not encountered a single instance of it, 
although my practice has furnished me with not a few 
cases of the genuine hour-glass contraction, such as I 
have described it. After quoting the statement of 
Professor Burns, that " in almost every instance, this 
contraction takes place, that he scarcely ever introduced 
his hand into the uterus, in a case of flooding, without 
meeting with it, whether the placenta had or had not 
been expelled," Dr. Ramsbotham intimates that he had 
mistaken the whole cavity of the uterus for an upper 
chamber, the os uteri for the constriction of the central 
fibers of the body, and the dilated vagina, — having in it 
a coagulum of blood, — for the low^er chamber! It is 
much more probable that Dr. Ramsbotham may have 
overlooked the os uteri, which is commonly lax and 



442 TREATMENT OF THE THIRD STAGE. 



gaping for several hours after labor, and mistaken the 
cervico-uterine orifice for it, in what he calls globular 
contraction of the uteras, than that the Scotch professor 
was so egregiously deceived, in the great number of 
cases attended by him. 

I am led, by the remark in the concluding part of 
the preceding paragraph, to examine into the reality of 
the other kinds of irregular contraction, which, according 
to Dr. Ramsbotham, are so much more common than 
the hour-glass contraction. It will be fair to allow him 
to describe them : " Sometimes the uterus contracts 
globularly on the placenta, sometimes longitudinally, as- 
suming somewhat the shape of a sugarloaf ; at others, 
it contracts with a corner, so that in one part or other 
there is a sack, in which the principal bulk of the pla- 
centa is retained ; the other portions of the organ being 
in a relaxed state. Sometimes it contracts with a sharp 
ridge anteriorly, something like a hog's back; but this 
is rare." Of these multifarious and grotesque contrac- 
tions I have only to say that they are not contractions 
at all, in the sense in which we are now considering 
irregular uterine contraction, that is, as offering an im- 
pediment to the escape of the placenta; but, it appears 
to me, they are the unequal contraction of the uterine 
fibers, resulting from preternatural adhesion of the pla- 
centa. Dr. Eamsbotham allows that morbid adhesion of 
the placenta is a frequent concomitant of his irregular 
contraction ; to me it is manifest that they are the ne- 
cessar}^ effects of such adhesions, and are not chargeable 
with the retention of the placenta. Whenever morbid 
adhesion exists, if the uterus retain its ordinary power 
of tonic contraction, every part of its parietes will con- 



MORBID RETENTION OF THE PLACENTA. 443 



tract in a greater degree than the part to which the 
placenta is connected, and thus alter the shape of the 
cavity variously, according as the placenta is attached 
to one or another of its parietes. This will explain all 
of Dr. Ramsbotham's contractions, except his globular^ 
which, it has been already insinuated, may have been 
hour-glass contraction ( Baudelocque's hour-glass con- 
traction, not Dr. Ramsbotham's ), in the cases wherein 
he thought he discovered it. If this were not its char- 
acter, I am, I confess, in the dark concerning it. My 
experience has, indeed, supphed me with cases of the 
placenta, shut up in the cavity of the uterus, by closure 
of the OS uteri, the uterus being sufficiently firmly con- 
tracted, and quite as globular as could be desired. But, 
in every such case, the labor had been badly managed, 
pains did not come on to expel the placenta; it was 
suffered to remain in the cavity, though separated, and 
sufficient time, twenty-four hours or upward, had elapsed 
to allow the os uteri to contract. Here, contraction of 
the OS uteri was not the cause of the retention of the 
placenta, however much it may be in the way of its ex- 
trication, but the want of expulsive contraction and the 
inefficiency of the practitioner, in permitting the pla- 
centa to remain until the os naturally closed upon it. 

The treatment of hour-glass contraction, which is the 
only irregular contraction that can operate as an imped- 
iment to the delivery of the placenta, is simple, though 
it may be difficult and painful in the execution. It con- 
sists in the introduction of the hand and the insinua- 
tion of the fingers, one after another, within the stric- 
tured portion of the uterus, for the purpose of dilating 
it and giving access to the upper chamber, where the 



444 TREATMENT OF THE THIRD STAGE. 



placenta is incarcerated. This stricture is usually so 
great as to leave an aperture no larger than the cord, 
around which it is formed, and so firm that very perse- 
vering efforts are required to overcome it. To be safe 
or successful, our efforts must not be violent but steady, 
and we must be content to gain our end by slow de- 
grees. It may take an hour or more to overcome the 
resistance of the constriction, and get the hand fully in 
the upper chamber, when the placenta is to be grasped, 
after separating it, if it be found adherent, and slowly 
withdrawn; observing whether the fundus contracts af- 
ter the hand, and if it do not, pressing against it, ma- 
king, at the same time, counter pressure externally with 
the other hand, until it is excited to contraction. 

The manual removal of the placenta, in cases of 
hour-glass contraction, is, as already intimated, a painful 
operation, — few operations are, indeed, more painful, — 
it will, therefore, be proper to do all we can to diminish 
the sufferings of the patient. A large dose of lauda- 
num, eighty to a hundred drops, may be administered ; 
and the extraction of the placenta should be deferred 
until the system is under its narcotic influence. I have 
not had an opportunity to try chloroform in a case of 
this kind; but from what I have seen of its effects, in 
obstetrical and surgical practice, I am convinced that it 
will be found more efficacious than opium. In a case of 
instrumental delivery that occurred in my practice, 
twelve months ago, it was found necessary to introduce 
the hand into the uterus to extract the placenta, re- 
tained by atony, and this was done without the slight- 
est manifestation of suffering, the patient being under 
the influence of chloroform. 



UTERINE HEMORRHAGE. 446 



Uterine hemorrhage. 
The last topic which will engage our attention is 
uterine hemorrhage, occurring in the third stage, either 
before or after the removal of the placenta. Uterine 
hemorrhage, during an}^ of the stages of labor, or the 
latter months of j^regnancy, before labor comes on, is not 
like the hemorrhages to which other organs are obnox- 
ious from morbid states, but resembles more hemorrhage 
from injuries, which come within the province of the 
surgeon. It is, in fact, essentially of the same nature. 
Wounded arteries and veins bleed, because they are 
cut, — the effiision of blood being ^mdj passive, in the 
sense, at least, that preternatural momentum of the cir- 
culation has nothing to do with causing it. As long as 
the circulation goes on, no matter at how feeble a rate, 
blood will continue to flow from the divided vessels, 
until they are secured by ligature, or stopped by coagula. 
Just so with regard to uterine hemorrhage, toward the 
close of pregnancy or at the time of parturition. Blood 
flows from the denuded orifices of the utero-placental 
arteries and veins, whenever the placenta is separated, 
and will continue to flow until it is arrested by coagula, 
or nature's ligatures. These ligatures consist in the 
muscular fibers of the uterus, that encircle the blood- 
vessels, and they are tied by the tonic contraction of the 
uterus. If the uterus be weU-contracted, the ligatures 
are tightly drawn ; if it be relaxed, they are loose about 
the vessels : hence the satisfaction of the intelligent ob- 
stetrician, if he find the uterus firmly contracted, after 
the expulsion of the child, and his anxiety (which he 



446 TREATMENT OF THE THIRD STAGE. 



must, however, keep to himself), if he find it flabby, or 
fail to find it at all. 

These hemorrhages have, on account of their pro- 
fuseness, been very appropriately denominated " flood- 
ings :" blood suddenly rushes from the uterus in a 
stream, deluging the bed and dripping through it, and 
unless speedily arrested, the patient is blanched by the 
draining of her vessels. The blood, thus pouring out, is 
chiefly venous, for the veins are much larger than the 
arteries, and they have not the power to close them- 
selves which the arteries possess, by the contractility of 
their coats, but are dependent on the surrounding mus- 
cular fibers. 

Uterine- hemorrhage occasionaUy occurs in the first 
and second stages of labor; but this happens so seldom, 
according to my experience, compared with its frequency 
in the third stage, that we have scarcely any reason to 
expect it in the former, but every reason to dread it in 
the latter, without great vigilance on our part, and some- 
times in spite of aU the vigilance we can bestow. We 
do not do our duty, unless we remember that it is a 
covert, as well as an open, enemy of parturient females, 
and may intrench itself in the womb, after having bar- 
ricaded the external orifice with coagula. In this con- 
cealed situation, it may sap the foundation of life, and 
the practitioner not be aware of danger until he sees the 
edifice tottering to its fall. Dr. Gooch very properly 
remarks, that the constitution suffers from this internal 
hemorrhage as if an equal quantity of blood were dis- 
charged externally, — the blood in either case being out 
of the circulation, — and consequently the danger is 
equally great. " I have," says he, " seen many cases of 



UTERINE HEMORRHAGE. 447 



internal hemorrhage. Not long since I was requested 
to attend at the examination of the body of a female 
who had died soon after delivery ; the labor appeared to 
have terminated favorably, and the accoucheur had left 
her : soon afterward she became pale and fainted : he 
was immediately sent for ; but just as he arrived she 
expired. There was no external discharge of blood ; he 
knew not to what so fatal a change could be imputed. 
As soon as we entered the bedroom to examine the 
body, we perceived that the abdomen was much above 
the level of the body, and appeared as prominent as that 
of a woman seven months gone with child. The uterus, 
on its exposure, was seen to be enormously distended ; 
and although there was no external evidence of hemorr- 
hage, on cutting into it we found a mass (amounting to 
a gallon) of coagulated blood " (1). We now and then 
hear of sudden deaths among parturient females, in all 
parts of the country, astounding the friends on account 
of their unexpectedness, nothing having occurred in the 
previous stages of the labor to prepare them for such a 
catastrophe. In many of these melancholy cases, con- 
cealed uterine hemorrhage was the fatal foe, — so much 
the more fatal because unsuspected. It should, there- 
fore, be engraven on the memory of every practitioner 
of midwifery, in capital letters, that uterine hemorrhage 

IN THE THIRD STAGE IS THE GREAT DESTROYER OF PARTU- 
RIENT WOMEN. 

These observations upon the nature and tendency of 
uterine hemorrhage, in this stage of labor, being pre- 
mised, we may proceed to consider the most effectual 

(1) Practical Compendium of Midwifery. 



448 TREATMENT OF THE THIRD STAGE. 



weapons with which we can arm ourselves when called 
to combat it. First, hemorrhage before the extraction of 
tlie flacenta. The treatment in this condition ought to 
be modified by the previous circumstances of the case. 
If a discharge of blood should take place immediately 
after the birth of the child, we may try frictions and 
pressure over the uterus, with the hope of exciting suf- 
ficient contraction to arrest it. These means not pro- 
ving efficacious as promptly as we desire, we may resort 
to eold^ either by repeatedly wetting our hands in cold 
water, while pressure and frictions are making with them 
on the naked abdomen, or by applying cloths from 
which cold water or a mixture of vinegar and water is 
wrung out. But if the discharge appear later, notwith- 
standing frictions and pressure had been used as pre- 
ventives, or in the event of the failure of these means 
quickly to control it, where it commences immediately 
after the birth of the child, it must be met by the intro- 
duction of the hand into the cavity of the womb, for the 
double purpose of compelling it to contract and of re- 
moving the placenta. In cases of internal hemorrhage, 
no time should be lost in trying the milder remedies, 
because by the time it is discovered, by the pallor of the 
patient's countenance, the feebleness of the pulse, faint- 
ness, sickness at the stomach, large size of the abdo- 
men, etc., she has already lost so much blood, and the 
uterus is so little disposed to contract, that we must 
use the club of Hercules to kill the hon of Nemsea, or it 
will kill our patients, — and this club is neither more 
nor less than the hand, carried into the uterus to press 
upon its internal surface, aided by counter pressure 



UTERINE HEMORRHAGE. 449 



from without, and to withdraw the placenta, as soon as 
it is perceived that the uterus is contracting. 

I have said that one of the objects of the hand's in- 
tromission is to excite uterine contraction, and I have 
been careful to give precedence to this indication, be- 
cause it is paramount. What would it avail to evacuate 
the uterus, by bringing away the placenta, and leave its 
walls as relaxed as an empty sack ? And yet this is 
the practice inculcated by M. Yelpeau, which can hardly 
be contemplated without a shudder; and it is surprising 
that neither his American translator nor the editor of 
the third edition of his midwifery, published in this 
country, protested against it. Speaking of hemorrhage 
before the delivery of the placenta, M. Velpeau says, 
^* Whether it depends upon inertia, spasm, plethora, or 
irritation of the womb, it is always a dangerous phe- 
nomenon, which we ought to make haste to combat ; if 
the presence of the placenta is not the only cause, it at 
least serves to keep it up and aggravate it ; we should, 
therefore, be diligent in extracting it, even although 
there should be inertia ! " (1) M. Yelpeau professes to 
be in doubt as to the cause of the hemorrhage, but he 
does not hesitate to say that it is " improperly attribu- 
ted to the noncontraction of the womb, in consequence 
of which the blood must flow in torrents from siqyposed 
orifices that remain gaping upon the internal surface of 
the organ," and then straightway he envelops himself 
and his reader in a fog of puerile conjectures. Now, if 

(1) An Elementary Treatise on Midwifery ; or Principles of 
Tokology and Embryology, translated from the French, by Charles 
D. Meigs, M. D., with notes and additions by William Harris, JI. 
D., Philadelphia, 1845, p. 544. 
29 



450 TREATMENT OF THE THIRD STAGE. 



there be any one principle in practical obstetrics firmly 
established, it is precisely this: that a relaxed uterus 
will bleed profusely, soon after the birth of the child, if 
the placenta be detached, while a contracted uterus can- 
not bleed ; and to call in question the existence of large 
vascular orifices, especially venous, where the placenta 
had been attached, is preposterous, because any one may 
see them, and thrust the end of his little finger into 
some of them. It is fortunate for M. Yelpeau that the 
uterus is prone to contract, on the introduction of the 
hand, and particularly when it is being withdrawn, else 
it cannot be doubted that his practice, in these cases, 
would prove disastrous in the extreme. This contrac- 
tion may, however, fail to take place, if no precautions 
be adopted to insure it : it cannot, therefore, be believed, 
by any one holding correct doctrine on this vital and 
deeply interesting subject, that the practice of M. Vel- 
peau is as successful as that which sound principles 
prescribe. 

In the treatment of hemorrhage, while the placenta 
is retained, I have said nothing of injecting the umbili- 
cal vein with cold vinegar and water, or brandy and 
water, of administering styptics, or even ergot, because 
none of these things can be relied on : the Hand, the 
Hand is the main chance. 

Secondly ; Hemorrhage after the extraction of the 
placenta. — The same indication is presented here as in 
the first case, namely, to excite uterine contraction ; but 
it may be fulfilled by other means, though the hand is 
to be held as tine chose de rese^^ve, in the event of their 
failure. These means are, 1. Firm pressure upon the 
naked abdomen, by both hands, with a movement of the 



UTERINE HEMORRHAGE. 451 



fingers as if we aimed to grasp the uterus and amass its 
flabby, floating parieties. When this manipulation is 
commenced, the uterus is nowhere to be felt; but if it 
be successful, we presently feel it gathering itself up 
and becoming hard to the touch. In proportion as the 
uterine globe is formed, from the preexisting chaos, the 
hemorrhage subsides, and when it feels uniformly hard,, 
we know that our patient is placed on terra firma, 

2. The application of cold, in the manner already di- 
rected, viz., by cloths wrung out of cold water, or by 
cold water, poured in a small stream from a pitcher or 
teapot on the abdomen. Cold cloths may likewise be 
applied to the vulva, and ice may be deposited in the 
vagina. Cold, freely and boldly used, is a powerful 
agent; and I have met with very few cases of hemor- 
rhage, of this kind, that did not yield to it, in conjunc- 
tion with grasping pressure. When such cases do occur, 
we must, as already intimated, introduce the hand into 
the uterus to arouse it from its stupor. It seems to 
have been a favorite practice of Dr. Gooch, to press with 
the hand against the bleeding surface, and with the open 
hand on the outside of the abdomen, make counter- 
resistance to the first on the inside; and in this way, he 
says, he has known the most profuse hemorrhage sup- 
pressed (1). My own experience does not enable me to 
decide on the merits of this particular manual operation, 
because, as already stated, I have seldom had occasion 
to insert my hand, in these cases ; it may, however, be 
doubted whether any special efficacy can be claimed for 



(1) Op. Cit., p. 154. 



452 TREATMENT OF THE THIRD STAGE. 



it, unless, indeed, pressure be made strong enough to 
contuse and staunch the bleeding vessels, independently 
of uterine contractions — a procedure not required by 
the nature of the case, — to say nothing of the risk of 
dangerous consequences. Contraction is emphatically 
the one thing needful. 

Some practitioners are in the habit of administering 
ergot, in the hemorrhage under consideration. There is 
no harm m giving the article, provided we put no trust 
in it. I mean to say that ergot might possibly do good ; 
but that its operation is too precarious to justify any 
one in relying on it, to the neglect of the more certain 
resources which have been pointed out. There is an- 
other expedient, adopted by some, and sanctioned by 
high authorities, which is not so harmless,— I allude to 
the tampon. To attempt to control hemorrhage from an 
empty and flaccid uterus, by plugging the vagina, is 
highly hazardous. We may, it is true, prevent the is- 
sue of blood by this expedient, but we can have no 
assurance that it will not continue to pom^ from the ves- 
sels and collect in the uterine cavity, until life is ex- 
hausted. It is better to contend with an open than a 
lurking enemy; for though we were fully able to cope 
with him, we might be circumvented by his wiles. Let 
the blood, then, have an unobstructed channel; we can, 
the more clearly, discern our patient's danger — which 
it is folly to hide from our eyes, — and shall be incited 
to more earnest efforts to save her from impending 
death. 



ERRATA 



The Author, having been so circumstanced as to 
exercise but a partial supervision of the press, begs the 
reader to excuse and correct the following errors: 

Page VII.— Preface— line 37, for first iJiis read Ms. 

" 9,— Text— line 3, for points read jjozn^ 

♦* 15, " " 14, " ascribed read descrihed. 

•' 52, " " 23, " indicate, read tndic'ietf. 

•* 74, " lines 10 and 20, for Gardier, read Gardien. 

" 129, " line 14, for a, read the. 

" 209, " " 14, " vagina, read vagina. 

*' 241, " . »' 24, " hand, read 72€t.d. 

" 242, " " 13, " capet, read ca-put. 

" 246, " *' 20, ** interval, read internal. 

" 265, " " 16, " ovals, read ovale. 

*' ,302, " " 24, " affected, read effected. 

" 367, ** *' 29, " position, read fresentations. 

" 362, " lines 15 and 19, for gultero, read gutiuro, 

" 364, " line 1, for specieux, read spacievx. 

*' 378, " " 27, " the, read then. 

*' 396, " '« 6, ** to, read helcw. 

" 406, " "22, " dependai t, read dejpe«dewf. 

" 420, " "3, " twist, read iivirl- 

" 426, " " 9, '* recosnized, read required. 

" 432, " " 7, " tandum read <an^ew. 



s/i- inM:i 



INDEX. 



CHAPTER I. 

The obstetric properties of the pelvis, - - - - 1 
Superior strait of tlie pelvis, — its boundaries, figure, and 
diameters, 4. Plane of the superior strait, 5. Its axis, 
6. Inferior strait, 6. Its diameters, 7. Its plane, 8-9. 
Its axis, 9. Pelvic excavation, 12. Difference among 
authors regarding its inclined planes, 12-13. Diameters 
of the excavation, 14. Axis of the excavation, 15-17. 

CHAPTER II. 

Obstetric aptitudes of the fetus, - - - - 18 
Attitude of the fetus in utero, 18. The fetus divided 
ideally into three parts, for the purpose of studying its 
dimensions and structure, 19. I. The cephalic extrem- 
ity or head; — commissures of its vault or superior por- 
tion, resulting from its imperfect ossification, 20. The 
fontanels, 21. Shape of the fetal head, 22. Its diame- 
ters, 23. Its circumferences, 24. Movements it can 
safely execute, 25. II. The pelvic extremity, 26. III. 
The trunk of the fetus, 26-27. The usual situation of 
the fetus in the uterine cavity, 28. Inquiry into the 
cause of the head being most frequently the dependent 
part; — the opinion of the ancients, 28. The researches 
of M. Dubois, which go to show that not the laws of 
gravity but those of life regulate the situation of the 
fetus in utero, and determine its presentation, when labor 
arrives, 29-34. 



464 INDEX. 



CHAPTER III. 
The appurtenances of the fetus, - - - _ 35 

Two entire membranes only are demonstrable at the close 
of pregnancy, 36. Fetal and maternal portions of the 
placenta, — views of Weber concerning, 38-41. John 
Hunter's account of placenta practically the same, 43. 
Placenta an organ of respiration for the fetus, 45. Dr. 
Blun dell's doubts, 47. The placenta supplies the fetus 
with nourishment, 49. The umbilical cord, — its anatomi- 
cal constituents, 50-52: Dispute whether the knots 
sometimes formed upon it can injure or destroy the fetus, 
53. The liquor amnii, 54. 

CHAPTER IV. 

The uterus considered as an organ of expulsion, - 55 
Description of the uterus in its unimpregnated state, 55-58. 
Arrangement of the muscular fibers of the gravid uterus, 
according to Sir Charles Bell and Madame Boivin, 60- 
62. The body and neck of the uterus, besides being 
distinguished by a clear line of demarcation and the dis- 
position of their muscular fibers, are not lined by the 
same kind of membrane, 63. Body and neck do not, 
according to Madame Boivin, concur in the production 
of the menstrual discharge, 64. They perform different 
offices during pregnancy, 65. The body provides for the 
reception, growth, and accommodation of the ovum, 65- 
72. The neck serves to retain the ovum, being plugged 
by a glutinous cement and refusing to be expanded until 
a short time before labor comes on, 73-74. The neck 
is the sphincter uteri, 75. The nerves of the gravid 
uterus, according to the dissections of Dr. Robert Lee, 
76-79. 

CHAPTER V. 

The efficient cause of labor, _ - . _ 80 

The chief efficient cause of labor is uterine contraction, 82. 
Uterine contraction is of two kinds, viz., muscular and 



INDEX. 455 



tonic, 83. Muscular contraction of the uterus : effect of 
the contraction of the oblique fibers, 84. Effect of the 
contraction of the concentric fibers, 85. Of the circular 
fibers of the neck, 86. All the fibers of the uterus con- 
tract simultaneously, — those of the body tending to 
expel, those of the neck to resist, the expulsion of the 
fetus, 86-87. Tonic contraction of the uterus acts 
when distention is removed, 88. Dispute whether the 
uterus is really distended by pregnancy, 88-90. Tonic 
contraction maintains what is acquired by muscular, and 
materially aids in expelling the fetus, 91. The dia- 
phragm and abdominal muscles assist, by their contrac- 
tions, in expelling the fetus, 91. These auxiliaries are 
brought into requisition in the second stage of labor, 
and the resultant of their force is in the direction of the 
pelvic outlets, 93. They support, also, the uterus, and 
excite it to more vigorous contraction, 93-94. 

CHAPTER yi. 
The determinative cause of labor, - . _ 95 

Baudelocque's theory of, 96. M. Adelon espouses this the- 
ory, and assigns other causes to aid it, such as the ex- 
ceeding irritability of the uterus toward the end of 
gestation, and the obliteration of some of the vessels 
of the placenta, 99. Objections to M. Adelon's views, 
100—101. Dr. Powers's explanation, viz., orificial irri- 
tation, arising from the contact of the ovum, excites 
the uterus to contraction, 101. Presumptive evidences 
of the truth of his doctrines, 102-104. Positive proof 
derived from the origination of parturient contractions 
by artificial irritation of the uterine orifice, 105; and 
the strengthening of them, when languid, in the same way, 
106. The objection of Dr. Dewees to the doctrine of 
orificial irritation, and the answers, 107-111. 

CHAPTER YII. 

PlIENOMEXA OF THE FIRST STAGE OF LABOR, - - - 112 

First, Pains, their nature and cause, 112-114. Secondly, 



456 INDEX. 



The " show," — mucous secretion, thiged with blood, 115. 
Thirdly, dilatation of the os uteri, 115. Fourthly, the 
membraneous pouch ; delusion to which it has given 
rise, viz., the supposition that the presenting part of the 
child ascends in the commencement of the pains, and de- 
scends when the pains reach their greatest intensity, 
117. Manner in which the os uteri is opened, 118-123. 
Uses of the membraneous pouch, 124. Dr. Dewees's 
puzzle, 125. 

CHAPTEK VIII. 

Treatment of the first stage of labor, - - - 127 

Dr. Denman's noninterference with it, 127-128. Dr. 
Hamilton warns against the danger of allowing the first 
stage to occupy too long a time, 129. His rule to have 
it completed within twelve or fourteen hours from its 
actual commencement, 130. Dr. Burns abridges the 
time to ten or twelve hours, 131. Argument in favor 
of the doctrine of Hamilton and Burns, viz., danger of 
uterine exhaustion ; denial of Dr. Churchill that the 
pains of first stage have such a tendency, 133. Answer 
to Dr. Churchill's statistics, 135. Obliquity of the uterus 
as a cause of retardation of the first stage, 136. Its 
modus operandi, 137. Obliquity, if not remedied by 
posture, is to be treated by hooking the os uteri, and 
drawing it toward the center of the pelvis, 138. Con- 
sequences of neglecting it well illustrated by case in the 
practice of Baudelocque, 139. Dr. William Hunter 
opposes interference, and recommends patience, 140. 
The proper answer to such opposition, 141. Dr. F. 
Ramsbotham's' groundless fears of lacerating or inflam- 
ing the OS uteri, by such handling, 142. Inefficient 
action of the uterus, as a cause of delay of the first 
stage, 143. Digital irritation of the uterine orifice, to 
excite more vigorous contractions, 144. Objections of 
Blundell, Ramsbotham, Churchill, and Dewees, 146-149. 
Dr. Dewees's inconsistency, 149. Testimony of Burns 
and Power in favor of orificial stimulation, 150-152. 



INDEX. 457 



CHAPTER IX. 

Treatment of the first stage, concluded, - - 154: 

Impeded action of the uterus, causing delay of tlie first 
stage, 154. Dr. Hamilton's band of tlie uterus, caught 
between tlie bead of the cbild and tbe pelvis of tbe mo- 
ther, and Dr. Goocb's flabby and edematous os uteri, are 
to be referred to this state, 155. Counter pressure, by 
the fingers, upon the margin of the os uteri, during 
the pains, is the proper remedy, 157. Morbidly re- 
sisted action of the uterus, commonly called rigidity 
of the OS uteri, a cause of protracted first stage, 158. Its 
formidable power, 159. Bloodletting one of the means 
of overcoming this obstacle, 161. Opium and tar- 
tarized antimony, 162. Dr. Kennedy's observations 
on the use of tartar emetic in obstetric practice, 163. 
Stramonium and belladonna applied to the os uteri, 164. 
Raising and supporting the os uteri, when the head 
descends, covered by the neck of the womb, 165. Dr. 
Hamilton's "undeveloped band of the cervix uteri," a 
modification of cervical resistance, 166. Its treatment, 
167. 

CHAPTER X. 

Common phenomena of the second stage, - - 168 

Rupture of the membranes, and escape of a portion of the 
liquor amnii, 168-169. The retention of a part of the liquor 
amnii subserves a most useful purpose, 169-170. The 
fetus is, by more powerful contractions, made to engage 
in OS uteri, vagina, and vulva, 171-172. The circulation 
of the blood is impeded or suspended, in the uterine ves- 
sels, during the parturient contractions of this stage, 174. 
Confirmation of this truth by obstetric auscultation, 175- 
177. Efi'ects of this impediment or suspension upon the 
fetus, 177-179. 



458 INDEX. 



CHAPTER XI. 

Common treatment of the second stage of labor, - 180 

Danger of too sudden expulsion of the fetus, illustrated by 
a case from Madame Laehapelle, 181. To guard against 
this, the membranes ought to be always ruptured, as soon 
as the OS uteri is dilated, 182. Dr. F. Ramsbotham ob- 
jects to this practice, 183. Dr. Dewees ruptures the 
membranes too soon, 184. The perineum must be sup- 
ported, 184-185. Inefficient action of the uterus may 
be remedied by the administration of ergot, 187. Modus 
operandi of ergot, and danger of the child from its im- 
proper use, 188. Testimony of different eminent practi- 
tioners as to the reality of the danger in question, 189— 
192. The danger incurred by the mother from the abuse 
of ergot, 19.3-196. The use of digital stimulation of the 
OS uteri, vagina, and perineum, as a substitute for ergot, 
197-199. 

CHAPTER XII. 
Impotent action of the uterus, - _ _ - 200 

State of the uterus in this case, and its effects on mother 
and child, 200-203. Signs of the life or death of the 
fetus, 204-207. Protracted first stage a cause of impo- 
tency in second stage, 208. Extraordinary resistance, 
from rigidity of soft parts, malposition of the fetus, or 
disproportion between it and the pelvis, may operate to 
induce this impotent condition, 209-210. Bloodletting 
and ergot of no avail in impotent labor, 211. The fin- 
gers can do no good, 212. Artificial delivery, instru- 
mental or manual, according to circumstances of the case, 
is the proper resource, 213-214. 

CHAPTER XIII. 

Presentations and positions of the fetus, - - 216 

M. Baudelocque's classification, 216. The classification of 
Madame Laehapelle, 218. That of M. Duges, which is 



INDEX. 459 



adopted in this work, 219. The attempt of MM. Nae- 
gele and Dubois to simplify the subject still further, and 
critical remarks, 220-224. Presentation of the vertex, 
— discrepancy among authors as to the positions it em- 
braces, 224-226. Nomenclature of vertex positions, — 
Duges's — the author's, 227. The relative frequency of 
vertex presentations and positions, 228. Presentation 
of the pelvic extremity of the fetus, 229. The positions 
it includes and their nomenclature, 230-231. Frequency 
of pelvic presentations, 232. Presentation of the face, — 
its positions and nomenclature, 233. Presentations of 
the right and left shoulders, — their positions and nomen- 
clatur^e, 234-236. 

CHAPTER XIY. 

The mechanism, diagnosis, and prognosis of vertex pre- 
sentations, ------ - 237 

Mechanism, — principle which governs it, 237. Mechanism 
of the first or left occipito-acetabular position of the ver- 
tex, 238-247. Mechanism of the second or right occi- 
pito-acetabular position, 247-248. Mechanism of the 
third or right occipito-sacro - iliac position, 249-252. 
Mechanism of the fourth or left occipito-sacro -iliac posi- 
tion, 2.53. Question whether the occiput most frequently 
rotates forward, under the symphysis pubis, or backward, 
into the hollow of the sacrum, in the third and fourth 
positions? 254-256. The various descriptions and ex- 
planations that have been given of the rotatory move- 
ment of the head, 257-269. Several causes cooperate in 
producing the rotation of the head, 270-272, Diagnosis 
272. Auscultation of some service where the diagnosis 
is obscured, 275. Prognosis, 276. 

CHAPTER XY. 

Manual assistance in vertex presentations, - - 277 

Officious practice, formerly in vogue, condemned, 277-280. 
Release of the head may, nevertheless, be promoted, by 
firm pressure upon the perineum, 281. It may be neces- 



m INDEX. 



sary to promote the passage of tlie shoulders, 282. The 
umbilical cord may he found encircling the neck, after 
the head is born, 283. What is to be done, 204. The 
treatment recjuired by the occipito-posterior positions 
of the vertex, 285. The expulsion of the head hin- 
dered by contraction of the cervix uteri about the neck 
of the child, 286. The cause and treatment of this ob- 
stacle, 287-289. 

CHAPTER XVI. 

Instrumental delivery in vertex presentation, - 290 

First, by the forceps. Description of the forceps, 291. 
G-eneral observations on delivery by the forceps, 292- 
297. Three situations of the head in the pelvic cavity 
to be discriminated in reference to forceps delivery, 298. 
Application of the forceps in the first situation of the 
head, 300. Its application in the second situation of the 
head, 302. Its application in the third situation of the 
head, 303. Secondly, delivery by the crotchet, 305. 
Vague and unsatisfactory directions given by authors 
generally for the performance of this operation, 306-310. 
Baudelocque's brief but luminous instructions, 310-311. 

CHAPTEE XVII. 

Mechanism, diagnosis, and prognosis op nates presenta- 
tion, 313 

Mechanism of the first or left dorso-iliac position, 314. 
Mechanism of the second or right-dorso-iliac position, 
317. Mechanism of the third or dorso-pubie, and of the 
fourth or dorso-sacral, positions, 318. In the latter, the 
occiput may rotate forward, or it may come down into the 
hollow of the sacrum, ,319. The difficulty with which 
the head is expelled, in the latter case, has not been cor- 
rectly understood, 320. Explanatory and critical re- 
marks, 321-325. Signs of nates presentation in general, 
326-330. Tangible marks of presentation and its seve- 
ral positions, 331-332. Tangible marks of the feet, 333. 
Of the knees, 335. Prognosis, 336. 



INDEX. 461 



CHAPTER XYIII. 
Treatment or nates presentation, _ _ . _ 340 
The practice fornierl}' sanctioned vras pragmatic and perni- 
cious, 340-342. The practice recommended by Gooch 
and others is reprehensible, 343-345. There is, never- 
theless, more frequent necessity for artificial aid in nates 
than in vertex presentations, 346. How this aid is to be 
rendered, 347-348. The extrication of the head may 
always be assisted, and this is often necessary, 349. If 
the uterus be in an exhausted condition, the blunt hook 
or forceps may be used, 350. 



CHAPTER XIX. 

Mechanism, diagnosis, and prognosis of face presenta- 
tion, 352 

Face presentations are either primitive or secondary, 352. 
Left fronto-iliac, and right fronto-iliac positions of the 
face, 353. Mechanism of face presentations, 354-360. 
Diagnosis, 360-361. Prognosis, 362-367. 



CHAPTER XX. 
Treatment of face presentations, - - - - 368 
The practice of redi-essing the head, when the face fuUy 
presents, is not to be observed, 369-370. The head 
may be redressed, when the face only partially presents, 
370-372. Of the operation of version in face presen- 
tations, 373-375. The forceps or crotchet in face pre- 
sentations, 375. Dr. Dewees's error as to the manner 
of using the forceps, 376. The necessity of vigilance 
to secure the chin's rotation toward the pubes — -Dr. 
Meigs's needless solicitude about this, 378. Madame 
Lachapelle improperly forbids pressure on the perineum, 
which assists the disengagement of the face, 379. 



462 INDEX. 



CHAPTER XXI. 

Mechanisn, diagnosis, and prognosis of shoulder pre- 
sentations, -_-..__ ggj 
Dr. Denman's account of spontaneous evolution, 382. The 
term, duplication of tlie fetus, more correctly expresses 
the manner in which it may be naturally expelled, 384, 
Description of the process, 384-385. Diagnosis, 386- 
388. Prognosis, 389. Circumstances under which we 
should be justifiable in expecting unassisted delivery, 
by the duplication of the fetus, 390. Case occurring in 
the practice of the author, 391. 

CHAPTER XXII. 
Treatment op shoulder presentations, - - . 393 

The indication presented is to turn the child and bring 
the feet foremost, 393. Conditions that must exist 
before the operation should be undertaken, 394. Po- 
sition of the patient, 395. Choice of a hand to op- 
erate with, 396. Parts of the operation — I. Intro- 
duction of the hand, 397. II. Seizing and bringing 
down the feet, 398. III. Extraction of the child, 399. 
Turning in the second or scapulo- sacral position of the 
right and left shoulder, 403. Turning in the first or 
scapulo-pubic position of the right shoulder, 404. Turn- 
ing in the first or scapulo-pubic position of t]ie left 
shoulder, 405. When turning is impracticable, delivery 
must be effected by embryotomy, 406. 

CHAPTER XXIII. 

Phenomena and management op the third stage op labor, 408 
The instrumentality employed in separating the placenta 
and membranes from the uterus, 408. Manner in which 
the placenta and membranes are separated and expelled, 
411. Ordinary management — I. Removal of the child 
to a convenient distance from the maternal genitals, 412. 
n. Hypogastric frictions and pressure to cause the uterus 
to contract, 413. HI. Section of the cord, 414. IV. 



INDEX. 463 



Extraction of the placenta, if it be detached, 415. 
Mode of extracting it. 418. Precautions to betaken to 
prevent lacerating the membranes, and leaving a fragment 
of them behind, 419. V. The application of a bandage 
to the abdomen, 420. VI. The administration of an an- 
odyne, 421. 

CHAPTER XXIY. 

Treatment of third stage of labor, _ _ _ _ 423 
Asphyxia of new-born infants among the first accidents 
demanding the attention of the accoucheur, 423. The 
causes of asphyxia neonatorum, 423-424. The bow- 
string not more murderous than ergotic contractions of 
the womb, 424. Simple asphyxia easily recognized, 424. 
Apoplectic asphyxia — its inducing causes, 425. Treat- 
ment of simple aspliyxia, 426. Mode of treatment re- 
commended by Desormeaux and P. Dubois, 426. Smel- 
lie's treatment, 427. The warm bath, 428. Artificial 
inflation of the lungs, 428. Bloodletting in apoplectic 
asj)hyxia the great remedy, 428. Bloodletting in sim- 
ple asphyxia, 429. Morbid retention of the placenta, 
430. Atony of the uterus, as a cause of the retention, 
430. The opinions of writers and practitioners as to 
the proper course of procedure, in the absence of uterine 
hemorrhage, 431. The introduction of the hand into 
the flaccid uterus, as an excitant, and to withdraw the 
placenta, 432. The manner in which that is accom- 
plished, 433. Opinion of Dr. Blundell, 435. Eeten- 
tion from morbid adhesion, 437. The introduction of 
the hand the safest and most reliable treatment, 439. 
Retention from irregular contraction of the uterus, 
440. Dr. F. Ramsbotham on hour-glass and other ir- 
regular contractions, 441—443. Treatment of hour- 

^ glass contraction, 443. Uterine hemorrhage, 445. Its 
treatment before extraction of the placenta, 448. The 
Hand the great remedy, 448-450. Treatment after ex- 
traction of the placenta — I. By firm pressure on the na- 
ked abdomen, 450. II. By the application of cold, 451. 
Administration of ergot of no avail, 452. The use of 
tamDon dangerous. 452. 



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